A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (Select all that apply)
Tilt the client's head backward
Move the client into high-Fowler's position
Apply pressure to the nares
Instruct the client to blow his nose
Place ice to the bridge of the client's nose
Correct Answer : B,C,E
These actions help to control bleeding, reduce blood pressure, and promote clotting.
a. Tilt the client's head backward. This is not recommended, as it can cause blood to drain into the throat and increase the risk of aspiration, nausea, or vomiting.
d. Instruct the client to blow his nose. This is not advisable, as it can dislodge any clots that have formed and worsen bleeding.
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Related Questions
Correct Answer is C
Explanation
Heparin is an anticoagulant that prevents the formation of new clots and the extension of existing clots. It is the drug of choice for treating acute pulmonary embolism, which is a life-threatening condition caused by a blood clot that travels to the lungs and blocks a pulmonary artery.
a) Dexamethasone is a corticosteroid that reduces inflammation and suppresses immune response. It is not indicated for treating pulmonary embolism, but it may be used for other pulmonary conditions, such as asthma or COPD.
b) Atropine is an anticholinergic that blocks the action of acetylcholine and increases heart rate and cardiac output. It is not indicated for treating pulmonary embolism, but it may be used for bradycardia or asystole.
d) Furosemide is a loop diuretic that increases urine output and reduces fluid volume and blood pressure. It is not indicated for treating pulmonary embolism, but it may be used for heart failure or edema.
Correct Answer is B
Explanation
White coating in the mouth, also known as oral candidiasis or thrush, is a serious adverse effect of fluticasone/salmeterol, which is a combination of an inhaled corticosteroid and a long-acting beta2 agonist. It is caused by fungal infection of the oral cavity due to suppression of the normal flora by the corticosteroid component. The client should report this symptom to the provider, as it may require antifungal treatment and discontinuation of the medication.
a) Dry oral mucous membranes is a common and mild adverse effect of fluticasone/salmeterol, which can be relieved by drinking water, chewing sugarless gum, or using artificial saliva. It does not require reporting to the provider or stopping the medication.
c) Sedation is not an adverse effect of fluticasone/salmeterol, but it may be caused by other medications, such as antihistamines, opioids, or benzodiazepines. The client should avoid driving or operating machinery if sedated and consult with the provider about possible drug interactions.
d) Increased appetite is not an adverse effect of fluticasone/salmeterol, but it may be caused by other factors, such as stress, boredom, or hormonal changes. The client should maintain a balanced diet and exercise regularly to prevent weight gain and promote health.
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