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 B

Explanation

Choice A reason: Pneumonia causes cough, chest pain, and dyspnea, not facial pain or nasal drainage primarily. Fever fits, but symptom location (lungs vs. sinuses) rules it out for these presenting complaints.

Choice B reason: Acute sinusitis matches pain over nose/eyes/forehead, purulent drainage, fever, and malaise. Bacterial or viral inflammation of sinuses causes these classic signs, aligning perfectly with the patient’s symptoms.

Choice C reason: Tuberculosis involves chronic cough, weight loss, and night sweats, not acute facial pain or drainage. It’s a lung infection, lacking sinus-specific symptoms, making it an unlikely diagnosis here.

Choice D reason: Pharyngitis causes throat pain, not sinus-area pain or nasal drainage. Fever and malaise fit, but the location and purulence point to sinusitis, not a pharyngeal infection, in this case.

A. Encourage the patient to engage in regular low-impact exercise. B. Advise the patient to limit fluid intake to prevent edema. C. Instruct the patient to wear tight-fitting shoes to improve circulation. D. Recommend strict bed rest to minimize pain.

Correct Answer is A

Explanation

Choice A reason: Low-impact exercise, like walking, enhances collateral circulation in PAD, increasing blood flow to ischemic muscles. It reduces claudication by stimulating angiogenesis and improving endothelial function, a cornerstone of evidence-based management to alleviate symptoms effectively.

Choice B reason: Limiting fluid intake addresses edema, not a primary PAD issue, which involves arterial insufficiency, not venous stasis. This strategy lacks scientific support for claudication relief, as hydration status doesn’t directly influence arterial perfusion.

Choice C reason: Tight shoes restrict circulation, worsening PAD by compressing arteries and exacerbating ischemia. Proper footwear is essential, but constriction contradicts vascular physiology, potentially increasing pain and tissue damage rather than improving blood flow.

Choice D reason: Bed rest reduces activity, promoting stasis and deconditioning in PAD, worsening claudication. Immobility decreases muscle pump action and collateral flow, conflicting with evidence that exercise improves symptoms, making this detrimental to recovery.

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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

A patient comes to the doctor’s office with the following complaints: Moderate to severe pain over the nose, eyes, and forehead, purulent nasal drainage, fever, and malaise. The nurse suspects the patient is suffering from ___________.

Correct Answer is B

Explanation

A 65-year-old patient with a history of Peripheral Artery Disease (PAD) presents to the clinic with complaints of intermittent claudication in the right leg. Which of the following management strategies should the nurse prioritize to improve the patient’s condition?

Correct Answer is A

Explanation

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