The nurse is caring for a patient experiencing epistaxis. What action should the nurse take first?
Obtain the patient's vital signs
Apply a cold compress to the patient's facial area.
Firmly pack the nostril with saline soaked gauze.
Instruct the client to sit forward and pinch the nose below the nasal bone.
The Correct Answer is D
A. Obtain the patient's vital signs: While monitoring vital signs is important, especially for detecting hypovolemia or underlying causes like hypertension, it is not the immediate priority. The nurse must first attempt to control the bleeding to prevent aspiration and continued blood loss.
B. Apply a cold compress to the patient's facial area: Cold compresses can help constrict blood vessels and reduce bleeding, but they are supportive measures. They should be done after primary pressure techniques have been initiated, not as the first-line intervention.
C. Firmly pack the nostril with saline soaked gauze: Nasal packing is typically a secondary measure used when direct pressure fails to stop the bleeding. It is more invasive and usually performed by trained personnel if conservative measures are ineffective.
D. Instruct the client to sit forward and pinch the nose below the nasal bone: Sitting forward prevents blood from flowing into the throat and airway, while pinching the soft part of the nose applies direct pressure to the bleeding vessels, which often successfully stops epistaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Crackles are heard in bases. – The nurse encourages the client to cough forcefully:
Crackles are caused by fluid in the alveoli and are often not cleared with coughing. Encouraging coughing may help with mucus, but for fluid-related crackles (e.g., in heart failure), diuretics or other interventions are more appropriate.
B. Wheezes are heard in central areas. – The nurse administers an inhaled bronchodilator:Wheezes result from narrowed airways, commonly seen in asthma or bronchospasm. Bronchodilators relax airway smooth muscle, improving airflow and reducing wheezing.
C. Vesicular sounds are heard over the periphery. – The nurse has the client breathe:
Vesicular breath sounds are normal over the peripheral lung fields. No action is needed when these sounds are heard, so prompting the client to breathe differently is unnecessary.
D. Hollow sounds are heard over the trachea. – The nurse increases the oxygen flow rate:Hollow, tubular sounds (bronchial) are expected over the trachea. These are normal findings and not an indication of hypoxia. Increasing oxygen unnecessarily could be harmful.
Correct Answer is B
Explanation
A. The client's sputum is white colored:White sputum may be normal for a client with COPD and often indicates chronic inflammation without infection. It does not signal an acute or emergent issue that requires immediate intervention.
B. The client's arterial blood gas CO₂ level is 76 mm Hg:A CO₂ level this high indicates significant hypercapnia, which can lead to respiratory acidosis and altered mental status. This finding reflects serious respiratory compromise and requires prompt intervention to prevent respiratory failure.
C. The client's pulse oximeter is 90%:While 90% is on the lower end of acceptable for clients with end-stage COPD, it is often tolerated due to their adapted baseline. It does not represent an immediate threat unless accompanied by other signs of deterioration.
D. The client has mild SOB when walking to the bathroom:Mild shortness of breath with exertion is expected in clients with advanced COPD. It reflects baseline activity tolerance and does not require urgent action unless symptoms worsen.
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