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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Radiation therapy can cause immunosuppression, which increases the risk of infection. The nurse should monitor the client for signs of infection such as fever, chills, malaise, or purulent drainage.
- Examine the skin for generalized urticaria. This is not a common side effect of radiation therapy, as urticaria is an allergic reaction that causes hives or welts on the skin. Radiation therapy can cause localized skin irritation, erythema, or dryness, but not generalized urticaria.
- Review laboratory test results for low hemoglobin. This is not a direct effect of radiation therapy, as hemoglobin is a component of red blood cells that carries oxygen in the blood. Radiation therapy can cause anemia, which is a low number of red blood cells, but not necessarily low hemoglobin.
- Monitor the mouth for signs of xerostomia. This is not relevant for a client who receives radiation therapy to treat lung cancer, as xerostomia is dry mouth caused by reduced salivary gland function. This can occur in clients who receive radiation therapy to treat head and neck cancer, but not lung cancer.
Correct Answer is D
Explanation
Smoking cessation is the most effective way to prevent chronic bronchitis, which is a type of chronic obstructive pulmonary disease (COPD) characterized by inflammation and excess mucus production in the
bronchi. Smoking is the main cause of chronic bronchitis, as it damages the cilia and mucous membranes of the airways, leading to chronic cough, sputum, and infection. Quitting smoking can reduce the risk of developing or worsening chronic bronchitis and improve lung function and quality of life.
a) Regular moderate exercise is beneficial for preventing chronic bronchitis, but not as effective as smoking cessation. Exercise can improve cardiovascular and respiratory health, increase oxygen delivery to the tissues, and enhance immune function. However, exercise alone cannot reverse the damage caused by smoking or prevent further deterioration of the airways.
b) Maintenance of ideal weight is beneficial for preventing chronic bronchitis, but not as effective as smoking cessation. Maintaining a healthy weight can reduce the workload on the heart and lungs, prevent obesity-related complications, and improve self-esteem and well-being. However, weight management alone cannot restore the normal structure and function of the airways or prevent chronic inflammation and mucus production.
c) Annual influenza immunization is beneficial for preventing chronic bronchitis, but not as effective as smoking cessation. Influenza immunization can protect against viral infections that can trigger or exacerbate chronic bronchitis symptoms, such as fever, cough, wheezes, and dyspnea. However, influenza immunization cannot prevent other causes of chronic bronchitis, such as bacterial infections, environmental pollutants, or genetic factors.
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