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?
"Place a warm, wet washcloth over your child's forehead and the bridge of their nose."
"Use your thumb and forefinger to apply pressure to the sides of your child's nose."
"Have your child lie down and turn their head to the side for 10 minutes."
“Tell your child to blow their nose gently, and then sit down and tilt their head backward."
The Correct Answer is B
A. "Place a warm, wet washcloth over your child's forehead and the bridge of their nose." Warm compresses may actually dilate blood vessels, which can worsen the bleeding. Cold compresses are preferred to help constrict vessels.
B. "Use your thumb and forefinger to apply pressure to the sides of your child's nose." This is the correct first-aid measure for epistaxis. The parent should pinch the soft part of the nose continuously for 10–15 minutes while the child leans forward.
C. "Have your child lie down and turn their head to the side for 10 minutes." Lying down can increase blood flow to the nose and may cause blood to be swallowed, which can lead to nausea or vomiting.
D. “Tell your child to blow their nose gently, and then sit down and tilt their head backward." Tilting the head back can cause blood to drain into the throat, increasing the risk of aspiration and stomach upset. Leaning forward is the proper position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B,C"}}
Explanation
- Urticaria: Urticaria (hives) is a hallmark sign of an allergic reaction, particularly latex allergy, and typically appears quickly following exposure to allergens. It is not seen in malignant hyperthermia or hypovolemic shock.
- Wheezing: Wheezing can occur in latex allergy due to bronchospasm or airway edema. While respiratory compromise may happen in malignant hyperthermia, it is typically due to muscle breakdown and CO2 retention, not bronchospasm. Wheezing is not expected in hypovolemic shock.
- Muscle rigidity: Generalized rigidity, especially of the jaw (masseter spasm), is a key early sign of malignant hyperthermia, a life-threatening reaction to certain anesthetics. It is not a symptom of latex allergy or hypovolemic shock.
- Hypercapnia: An elevated PaCO₂ is an early, sensitive marker of malignant hyperthermia, resulting from increased CO₂ production due to sustained muscle contraction. This does not occur in latex allergy or hypovolemic shock.
- Tachycardia: Elevated heart rate can be seen in all three conditions: in malignant hyperthermia due to increased metabolic demand, in latex allergy due to anaphylactic reaction, and in hypovolemic shock as a compensatory response to fluid loss.
Correct Answer is D
Explanation
A. Use tubing that does not have a filter in the drip chamber. Blood transfusion tubing must have a filter to trap clots, cellular debris, and other particulates, ensuring the safe administration of blood products.
B. Use an IV catheter that is at least 24-gauge. A larger bore catheter (18- to 20-gauge) is preferred for blood transfusions to reduce the risk of hemolysis and allow adequate flow. A 24-gauge is too small for standard transfusion protocols.
C. Attach a single line administration set. A Y-type tubing set is typically used, allowing for connection to both the blood product and normal saline. This setup enables flushing before and after the transfusion and provides a safe delivery system.
D. Prime the tubing with 0.9% sodium chloride. Only 0.9% sodium chloride (normal saline) should be used to prime the tubing, as it is compatible with blood products and prevents hemolysis or clot formation. Dextrose or other solutions can cause serious reactions.
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