Which action would the nurse take first when a patient develops epistaxis (nose bleed)?

Instill a vasoconstrictor medication into the affected nare.

Pack the affected nare tightly with an epistaxis balloon.

Obtain silver nitrate that may be needed for cauterization.

Apply squeezing pressure to the nostrils for 10 minutes.

Answer and Explanation

The Correct Answer is D

Choice A reason: Vasoconstrictors like oxymetazoline shrink vessels, aiding epistaxis control. It’s a secondary step requiring preparation, not first, as direct pressure is faster, non-invasive, and effective for initial hemostasis in most anterior bleeds.

Choice B reason: Packing with a balloon stops severe bleeding but is invasive and later in management. Pressure is the first, simpler action; packing escalates care unnecessarily before basic measures are tried in acute epistaxis.

Choice C reason: Silver nitrate cauterizes vessels, useful for persistent bleeding. It’s not first, requiring setup and assessment after pressure fails, as most epistaxis resolves with compression, making this a subsequent intervention.

Choice D reason: Squeezing nostrils compresses Kiesselbach’s plexus, stopping most anterior nosebleeds within 10 minutes. It’s the immediate, evidence-based first action, non-invasive, and effective, prioritizing rapid control before escalating to other methods.

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Correct Answer is D

Explanation

Choice A reason: Streptomycin treats TB, but persistent AFB after 2 months suggests resistance or non-adherence. Requesting it now skips assessing compliance, which is critical first, as adding drugs prematurely may worsen resistance.

Choice B reason: Injectable antibiotics (e.g., amikacin) address resistant TB, but without confirming adherence, this is premature. Non-compliance is common; discussing this assumes resistance without evidence, delaying root cause investigation.

Choice C reason: Teaching about drug-resistant TB is relevant if resistance is confirmed, not assumed. Positive AFB may reflect non-adherence, so education is secondary to verifying medication use, which drives next steps.

Choice D reason: Asking about adherence checks if the patient took drugs as directed, a common reason for persistent AFB. Non-compliance delays sputum conversion, making this the first action to guide further treatment decisions.

A. Encourage fluid intake B. Administer prescribed diuretic as ordered. C. Monitor daily weight and fluid intake/output. D. Educate the patient about low-sodium dietary choices.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Encouraging fluid intake worsens heart failure by increasing preload and congestion. Restriction (e.g., 2L/day) is standard to prevent overload, as excess volume exacerbates dyspnea and edema in compromised hearts.

Choice B reason: Administering diuretics like furosemide reduces fluid overload, easing heart failure symptoms. It lowers pulmonary pressure and edema by enhancing excretion, a critical action to stabilize patients and improve breathing.

Choice C reason: Monitoring weight and fluid balance tracks retention in heart failure; a 2-3 lb gain signals worsening. It guides therapy adjustments, ensuring effective management of volume status and preventing decompensation.

Choice D reason: Educating on low-sodium diets (<2g/day) prevents fluid retention in heart failure. Sodium draws water into vessels, worsening congestion; this empowers patients to control symptoms and supports long-term stability.

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Which action would the nurse take first when a patient develops epistaxis (nose bleed)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After 2 months of prescribed treatment with isoniazid, rifampin, pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action would the nurse take next?

Correct Answer is D

Explanation

Identify the actions the nurse should take to manage this patient’s heart failure effectively. (Select all that apply)

Correct Answer is ["B","C","D"]

Explanation

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