A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take?
Have the client gently blow clots from his nose every 5 min
Instruct the client to sit with his head hyperextended
Apply ice compresses to the back of the client’s neck
Pinch the soft portion of the client’s nose for 10 min
The Correct Answer is D
Choice A reason: Having the client gently blow clots from his nose every 5 min is an incorrect action, because it can increase the bleeding and trauma to the nasal mucosa. The client should avoid blowing or picking his nose.
Choice B reason: Instructing the client to sit with his head hyperextended is an incorrect action, because it can cause the blood to drain into the throat and increase the risk of aspiration or vomiting. The client should sit with his head tilted forward.
Choice C reason: Applying ice compresses to the back of the client’s neck is an incorrect action, because it has no effect on the bleeding site. The nurse should apply ice compresses to the bridge of the nose or the cheeks to constrict the blood vessels and reduce the bleeding.
Choice D reason: Pinching the soft portion of the client’s nose for 10 min is a correct action, because it applies direct pressure to the bleeding site and allows clot formation. The nurse should instruct the client to breathe through his mouth and avoid swallowing the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect instruction, because it is not necessary to take this medication for the rest of your life to prevent recurrence. Isoniazid is usually taken for 6 to 9 months, or as prescribed by the provider, to treat active TB or latent TB infection.
Choice B reason: This is the correct instruction, because your provider will monitor your liver function while you are taking this medication. Isoniazid can cause hepatotoxicity, which is a serious side effect that can damage the liver and cause jaundice, nausea, vomiting, or abdominal pain.
Choice C reason: This is an incorrect instruction, because you should avoid alcohol intake while you are taking this medication. Alcohol can increase the risk of hepatotoxicity and interfere with the metabolism of isoniazid.
Choice D reason: This is an incorrect instruction, because it is not recommended to take this medication with a meal to increase absorption. Isoniazid should be taken on an empty stomach, at least 1 hour before or 2 hours after a meal, to ensure optimal absorption and effectiveness.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect route, because maternal-fetal transmission of hepatitis A is very rare and occurs only if the mother has acute hepatitis A during the third trimester of pregnancy.
Choice B reason: This is the correct route, because fecal-oral contamination of hepatitis A is the most common mode of transmission. Hepatitis A is a viral infection that affects the liver and is spread through ingestion of contaminated food or water, or contact with infected feces.
Choice C reason: This is an incorrect route, because genital sexual contact of hepatitis A is uncommon and occurs only if there is oral-anal contact with an infected person.
Choice D reason: This is an incorrect route, because blood to blood transmission of hepatitis A is also uncommon and occurs only if there is exposure to infected blood or blood products, such as through needle sharing or transfusion.
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