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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Physical therapy for homebound therapy services:Physical therapy is not routinely indicated in TB management unless the patient has specific mobility deficits. TB treatment focuses more on medication adherence and infection control rather than physical rehabilitation.

B. Occupational therapy for job retraining:There is no direct indication for job retraining in a TB patient unless the illness has caused long-term disability or affected occupational function, which is not suggested in this scenario.

C. Community social worker for Meals on Wheels:Meals on Wheels may assist with nutrition, but it is not specific to TB care. Social services do not directly ensure adherence to TB therapy, which is crucial for treatment success and public health safety.

D. Visiting Nurses for directly observed therapy:Directly observed therapy (DOT) ensures the client takes prescribed TB medications under supervision, which is essential to prevent noncompliance, reduce drug resistance, and promote cure. Visiting nurses are best positioned to provide this support during long-term outpatient TB treatment.

A. administer an NSAID for discomfort B. assess the patient's 02 saturation C. check the MAR for an order for a mild sedative D. take the patient off of oral fluids

Correct Answer is B

Explanation

A. Administer an NSAID for discomfort:While fever and discomfort may contribute to restlessness, NSAIDs do not address the most urgent concern, which is potential hypoxia. Treating symptoms without first assessing respiratory function may delay appropriate intervention.

B. Assess the patient's O₂ saturation:Increasing restlessness and confusion in a pneumonia patient can be early signs of hypoxia, especially in older adults. Oxygen saturation should be evaluated immediately to determine if the patient needs supplemental oxygen or further respiratory support.

C. Check the MAR for an order for a mild sedative:Sedatives may worsen confusion and can depress respiratory drive, particularly in hypoxic patients. Administering a sedative without first ruling out hypoxia may pose significant risk.

D. Take the patient off of oral fluids:Unless there are clear signs of aspiration or decreased level of consciousness, discontinuing oral fluids is not an appropriate first step. Hydration is important in pneumonia to help thin secretions and support recovery.

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Naxlex Comprehensive Predictor Exams

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