Nokea
A parent reports that her child has developed a bloody nose. Which action should the nurse instruct the parent to take to control the bleeding?
- A. Pinch the nostrils for 5 minutes and then recheck for bleeding.
- B. Maintain the child in a sitting position with the head tilted backward.
- C. Lay the child down with a pillow tucked under the neck and stay with the child to keep the child calm.
- D. Have the child sit with the head tilted forward and hold pressure on the soft part of the nose for a period of 10 minutes.
Correct Answer: D
Rationale: The child should be positioned erect, sitting with head tilted forward to avoid blood dripping posteriorly to the pharynx. The soft part of the nose should be tightly pinched against the center wall for 10 minutes, and the parent should be instructed that this pinch should be timed by a clock, not estimated. The parent should be told not to release pressure for 10 minutes. The child is encouraged to remain calm and quiet and to breathe through the mouth.
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The nurse is caring for a client who has just undergone a liver biopsy. Which of the following interventions is most important in the immediate post-procedure period?
- A. Keep the client on the right side for 2 hours.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Apply heat to the biopsy site.
Correct Answer: A
Rationale: Keeping the client on the right side for 2 hours post-liver biopsy applies pressure to the site, reducing the risk of bleeding.
A client with chronic obstructive pulmonary disease is bedridden at home and gets little exercise. The nurse should assess the client for which of the following?
- A. Increased sodium retention.
- B. Increased calcium excretion.
- C. Increased insulin use.
- D. Increased red blood cell production.
Correct Answer: B
Rationale: Prolonged immobility in COPD increases calcium excretion due to bone resorption, risking osteoporosis. The other options are not directly related to immobility.
The clinic nurse is reviewing the laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following laboratory findings indicates that the allopurinol is having the desired effect?
- A. Decreased serum uric acid level.
- B. Decreased serum potassium level.
- C. Increased serum calcium level.
- D. Increased hemoglobin level.
Correct Answer: A
Rationale: Allopurinol reduces serum uric acid levels by inhibiting xanthine oxidase, which is its therapeutic effect in treating gout.
The nurse is evaluating the client's potential for development of a pressure sore. Which of the following individual characteristics would be the best indicator of risk for the client's developing a pressure sore?
- A. The client's nutritional status.
- B. The client's circulatory status.
- C. The client's mobility status.
- D. The client's orientation status.
Correct Answer: C
Rationale: Immobility is the primary risk factor for pressure sores, as it leads to prolonged pressure on tissues.
The nurse is caring for a client receiving chemotherapy. Which precaution is most important?
- A. Use standard precautions.
- B. Wear a gown and gloves.
- C. Place the client in isolation.
- D. Monitor for fever.
Correct Answer: D
Rationale: Monitoring for fever is critical, as chemotherapy increases infection risk due to immunosuppression.