The nurse in a school clinic is caring for a 7-year-old girl who comes in for epistaxis. The nurse will initiate which of the following interventions? (Select the 2 responses that apply)
Apply a heat pack to the bridge of the nose.
Lightly suction blood from nares and mouth.
Have the child tilt her head forward.
Have the child sit upright.
The Correct Answer is C
Choice A reason: Applying a heat pack to the bridge of the nose is not recommended as it may increase blood flow and worsen the bleeding.
Choice B reason: Lightly suctioning blood from nares and mouth is not typically necessary and could be uncomfortable for the child.
Choice C reason: This is one of the correct choices. Tilting the head forward prevents blood from flowing down the throat, which can cause nausea or vomiting.
Choice D reason: This is one of the correct choices. Sitting upright reduces blood pressure in the veins of the nose and may help slow the bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Limiting water intake is not recommended as adequate hydration is important, especially when sick.
Choice B reason: Checking blood glucose every 8-12 hours is not frequent enough; it should be monitored more often during illness.
Choice C reason: Drinking juice every hour is not necessary and could lead to hyperglycemia if not balanced with insulin.
Choice D reason: This is the correct choice. It is crucial to continue administering insulin as prescribed to manage blood glucose levels, even if the child is not eating as much.
Correct Answer is B
Explanation
Choice A reason: Trimming toenails straight across is a general foot care recommendation but is not the most critical for preventing complications from an arterial ischemic leg ulcer.
Choice B reason: This is the correct choice. Daily inspection of the feet for skin breakdown is crucial for early detection and prevention of complications associated with arterial ischemic leg ulcers.
Choice C reason: Keeping legs elevated can help reduce swelling but is not as critical as daily foot inspection for preventing ulcer-related complications.
Choice D reason: Wearing shoes and socks is important for protecting the feet but does not directly prevent complications from an arterial ischemic leg ulcer.
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