Which action would the nurse take first when a patient develops epistaxis (nose bleed)?

Instill a vasoconstrictor medication into the affected nare.

Pack the affected nare tightly with an epistaxis balloon.

Obtain silver nitrate that may be needed for cauterization.

Apply squeezing pressure to the nostrils for 10 minutes.

Answer and Explanation

The Correct Answer is D

Choice A reason: Vasoconstrictors like oxymetazoline shrink vessels, aiding epistaxis control. It’s a secondary step requiring preparation, not first, as direct pressure is faster, non-invasive, and effective for initial hemostasis in most anterior bleeds.

Choice B reason: Packing with a balloon stops severe bleeding but is invasive and later in management. Pressure is the first, simpler action; packing escalates care unnecessarily before basic measures are tried in acute epistaxis.

Choice C reason: Silver nitrate cauterizes vessels, useful for persistent bleeding. It’s not first, requiring setup and assessment after pressure fails, as most epistaxis resolves with compression, making this a subsequent intervention.

Choice D reason: Squeezing nostrils compresses Kiesselbach’s plexus, stopping most anterior nosebleeds within 10 minutes. It’s the immediate, evidence-based first action, non-invasive, and effective, prioritizing rapid control before escalating to other methods.

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Correct Answer is C

Explanation

Choice A reason: Respiratory rate dropping to 18 breaths/min may suggest improvement or fatigue, not worsening, in respiratory status. Normal range (12-20) makes this less alarming than signs of increased breathing effort.

Choice B reason: Oxygen saturation rising to 90% on 2 L indicates better oxygenation, not worsening. It reflects treatment response, improving gas exchange, so this finding contradicts a decline in respiratory status.

Choice C reason: Increased accessory muscle use signals worsening respiratory distress, as it compensates for airway resistance or fatigue. It reflects higher work of breathing, a critical sign of decompensation needing intervention.

Choice D reason: Productive cough with yellowish sputum suggests infection, not immediate worsening of respiratory mechanics. It’s a chronic sign, less urgent than accessory muscle use indicating acute respiratory effort escalation.

A. Ask the healthcare provider about prescribing Streptomycin. B. Discuss injectable antibiotics with the health care provider. C. Teach about drug-resistant TB. D. Ask the patient whether medications were taken as directed.

Correct Answer is D

Explanation

Choice A reason: Streptomycin treats TB, but persistent AFB after 2 months suggests resistance or non-adherence. Requesting it now skips assessing compliance, which is critical first, as adding drugs prematurely may worsen resistance.

Choice B reason: Injectable antibiotics (e.g., amikacin) address resistant TB, but without confirming adherence, this is premature. Non-compliance is common; discussing this assumes resistance without evidence, delaying root cause investigation.

Choice C reason: Teaching about drug-resistant TB is relevant if resistance is confirmed, not assumed. Positive AFB may reflect non-adherence, so education is secondary to verifying medication use, which drives next steps.

Choice D reason: Asking about adherence checks if the patient took drugs as directed, a common reason for persistent AFB. Non-compliance delays sputum conversion, making this the first action to guide further treatment decisions.

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Which action would the nurse take first when a patient develops epistaxis (nose bleed)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Based on the patient’s respiratory assessment and history, which assessment finding would indicate a worsening of Maria’s respiratory status?

Correct Answer is C

Explanation

After 2 months of prescribed treatment with isoniazid, rifampin, pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action would the nurse take next?

Correct Answer is D

Explanation

After change-of-shift report, which patient would the nurse assess first?

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