A nurse receives a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the parent?
"Have your child lie down and turn their head to the side for 10 minutes.”
"Place a warm, wet washcloth over your child's forehead and the bridge of their nose.”
"Tell your child to blow their nose gently and then sit down and but their head backward.”
“Use your thumb and forefinger to apply pressure to the sides of your child's nose”
The Correct Answer is D
Rationale:
A. "Have your child lie down and turn their head to the side for 10 minutes." Lying down increases blood flow to the head, which can worsen the nosebleed or cause aspiration if blood is swallowed. Upright posture is preferred to reduce venous pressure in nasal vessels.
B. "Place a warm, wet washcloth over your child's forehead and the bridge of their nose." Warm compresses can dilate blood vessels and worsen bleeding. Cold compresses are more appropriate to constrict blood vessels and reduce blood flow.
C. "Tell your child to blow their nose gently and then sit down and put their head backward." Blowing the nose can dislodge clots and worsen bleeding. Tilting the head back can cause blood to run down the throat, increasing the risk of nausea, vomiting, or aspiration.
D. "Use your thumb and forefinger to apply pressure to the sides of your child's nose."
Pinching the soft part of the nose for 10–15 minutes while the child leans slightly forward is the first-line intervention for epistaxis. This reduces bleeding and prevents aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Temperature 37.7° C (99.9° F): This temperature is only slightly elevated and not strongly indicative of infection. Endometritis typically presents with a fever above 38°C (100.4°F), reflecting a more pronounced inflammatory response.
B. Polyuria: Increased urine output is not a characteristic sign of endometritis. It may be seen with conditions such as diabetes mellitus or post-diuresis but is unrelated to uterine infection.
C. Malodorous lochia: Foul-smelling lochia is a key clinical sign of endometritis, indicating infection of the uterine lining. It often accompanies uterine tenderness, fever, and possibly abdominal pain.
D. Heart rate 56/min: Bradycardia is not typical in endometritis. Instead, clients may present with tachycardia as part of the systemic inflammatory response to infection. A low heart rate would be unexpected.
Correct Answer is C
Explanation
Rationale:
A. “I can infuse the medication at a faster rate”: Vancomycin must be infused slowly, typically over 60–120 minutes, to prevent adverse effects such as Red Man Syndrome. Increasing the infusion rate is unsafe and not appropriate.
B. “I can start the medication 30 minutes earlier.” While minor time adjustments may be acceptable, this choice limits flexibility unnecessarily. Medication timing should follow institutional policy, which generally allows a 30-minute window before and a 2-hour window after the scheduled time.
C. “I have up to 2 hours after the usual scheduled time to give you this medication”: This reflects standard medication administration guidelines for time-critical medications like antibiotics. Giving vancomycin within 30 minutes before or up to 2 hours after the scheduled time is acceptable and safe.
D. “I can adjust the time and schedule for when it's convenient for you.” While patient preferences are important, antibiotic timing must align with dosing schedules to maintain therapeutic levels. Adjustments must follow clinical guidelines, not personal convenience.
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