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: Non-opioid analgesics are typically not strong enough to manage the severe pain associated with a sickle cell crisis.
Choice B reason: Guided imagery can be a helpful adjunct, but it is not the primary method of pain control during a crisis.
Choice C reason: Diversional activities may help distract from the pain but are not sufficient as the sole method of pain management.
Choice D reason: This is the correct choice. An IV PCA (patient-controlled analgesia) allows the child to manage pain effectively and is appropriate for severe pain during a sickle cell crisis.
Correct Answer is ["B","E"]
Explanation
Choice A reason: Tripod positioning is a more severe sign, indicating increased work of breathing.
Choice B reason: This is one of the correct choices. Nasal flaring is a mild symptom of respiratory distress, indicating increased effort to breathe.
Choice C reason: Confusion is a more severe symptom, suggesting hypoxia affecting brain function.
Choice D reason: Cyanosis is a severe sign of respiratory distress, indicating poor oxygenation.
Choice E reason: This is one of the correct choices. Tachypnea, or rapid breathing, is a mild symptom of respiratory distress.
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