Nokea
A patient comes to the health nurse at the workplace with epistaxis. The patient reports frequent nosebleeds that have usually been controlled without intervention. Which assessment would be the most helpful after the nurse has stopped the bleeding?
- A. Obtain a blood pressure.
- B. Record the approximate amount of blood lost.
- C. Inquire about a headache.
- D. Record the last episode of epistaxis.
Correct Answer: A
Rationale: Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis. In addition, epistaxis can be a complication of untreated hypertension.
You may also like to solve these questions
Which action is the purpose of the cilia?
- A. Warm and moisturize inhaled air.
- B. Sweep debris toward nasal cavity.
- C. Stimulate cough reflex.
- D. Produce mucus.
Correct Answer: B
Rationale: The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate the cough reflex, but not the cilia themselves.
The nurse caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. Which action is appropriate based on this assessment?
- A. Document the tidaling.
- B. Elevate the head of the bed and notify charge nurse of malfunction of drainage system.
- C. Add more sterile water to the water seal chamber.
- D. Turn patient to the affected side.
Correct Answer: A
Rationale: Tidaling or fluctuation in the water seal drainage is an indicator that the negative pressure is preserved and the system is working normally. Document this normal finding.
How should the newly diagnosed patient who has been prescribed isoniazid (INH) for the treatment of active tuberculosis (TB) be advised?
- A. Report redness and swelling of extremities.
- B. Be aware that the therapy is long term.
- C. Monitor renal function every several months.
- D. Rise slowly to avoid dizziness.
Correct Answer: B
Rationale: INH therapy is long term. The patient should be advised to get regular liver studies and report tingling and numbness of the extremities.
The older adult patient with long-term emphysema reports experiencing a sharp pleuritic pain after a severe period of coughing. The patient's heart rate and respiratory rate have increased. Auscultation reveals no breath sounds on the left side. These are signs and symptoms of which condition?
- A. Pulmonary embolus
- B. Spontaneous pneumothorax
- C. Early signs of unilateral pneumonia
- D. An attack of asthma
Correct Answer: B
Rationale: Spontaneous pneumothorax can be caused by a ruptured bleb in a patient with long-term emphysema. The disorder causes chest pain, dyspnea, and anxiety associated with air hunger.
The nurse assessing an 11 year old who is having an asthma attack expects to hear which adventitious sounds?
- A. Friction rub.
- B. Expiratory wheezes
- C. Crackles.
- D. Absent breath sounds.
Correct Answer: B
Rationale: The narrowed bronchioles characteristic of an asthma attack would produce wheezes, which are high-pitched whistling sounds.