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

Answer and Explanation

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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Correct Answer is C

Explanation

Agitation is a sign of hypoxemia, as the brain is deprived of oxygen and becomes irritable and restless.

The other options are not correct because:

Nausea is not a specific manifestation of hypoxemia, as it can have many other causes such as medication side eﬀects, gastrointestinal disorders, or anxiety.
Dysphagia is difficulty swallowing, which is not related to hypoxemia or asthma. It can be caused by neurological, muscular, or structural problems in the throat or esophagus.
Hypotension is low blood pressure, which is not a typical manifestation of hypoxemia or asthma. It can be caused by dehydration, blood loss, shock, or heart failure.

A. Dexamethasone B. Atropine C. Heparin D. Furosemide

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.

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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)

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