The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

Side-lying with the head slightly elevated.

Standing with the head leaning backward.

Sitting up and leaning forward.

Supine with the legs raised.

Answer and Explanation

The Correct Answer is C

A)   Incorrect- This position is not ideal for managing a nosebleed because it does not promote drainage and may lead to blood flowing down the throat.
B)   Incorrect- Leaning the head backward can cause blood to flow down the throat and may lead to choking or aspiration.
C)   Correct- Placing the child in a sitting position and leaning forward helps prevent blood from flowing down the back of the throat, which can lead to choking or aspiration. Leaning forward allows the blood to drain out through the nostrils.
D)   Incorrect- Placing the child in a supine position with raised legs is not recommended for managing a nosebleed, as it may lead to blood flowing down the throat.

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Correct Answer is B

Explanation

A) Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B) Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C) Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D) Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.

A. Stop the Infusion. B. Assess vital signs. C. Contact the healthcare provider. D. Initiate an adverse event report. E. Document reaction to the drug.

Correct Answer is A,B,C,D,E

Explanation

A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to
the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.

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The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

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Naxlex Comprehensive Predictor Exams

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

Correct Answer is B

Explanation

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)

Correct Answer is A,B,C,D,E

Explanation

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