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Thirty minutes after the nurse removes a nasogastric tube that has been In place for seven days, the patient experiences epistaxis (nosebleed). Which of the following nursing actions is most appropriate to control the bleeding? a.Apply pressure by pinching the anterior portion of the for five to ten minutes
- A. Place the patient in a sitting position with the neck hyperextended
- B. Pack the nostrils with gauze and keep the gauze in piace for four to five days
- C. Apply ice compresses to the patient's forehead and back of the neck
Correct Answer: A
Rationale: The most appropriate nursing action to control the bleeding in this situation is to apply pressure by pinching the anterior portion of the nose for five to ten minutes. This is a common first aid technique used to stop nosebleeds, known as epistaxis. Applying pressure helps promote clotting and stops the bleeding. Placing the patient in a sitting position with the neck hyperextended or packing the nostrils with gauze for several days are not recommended first-line actions for controlling a nosebleed. The use of ice compresses to the forehead and neck may constrict blood vessels but is not as effective as direct pressure to the nose in this case.
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While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining the client's medication history, the nurse should determine if the client keeps which medication on hand?
- A. Diphenhydramine hydrochloride (Benadryl)
- B. Guaifenesin (Robitussin)
- C. Pseudoephedrine hydrochloride (Sudafed)
- D. Loperamide (Imodium)
Correct Answer: A
Rationale: The nurse should determine if the client keeps diphenhydramine hydrochloride (Benadryl) on hand because it is an antihistamine medication commonly used to treat allergic reactions, including those caused by bee stings. In the event of a bee sting reaction, diphenhydramine can help reduce itching, swelling, and other symptoms associated with the allergy. It is important for individuals who are allergic to bee stings to have diphenhydramine readily available for prompt treatment in case of an allergic reaction.
. Which of the following instructions should be included in the teaching plan for a client requiring insulin?
- A. Administer insulin after the first meal of the day.
- B. Administer insulin at a 45-degree angle into the deltoid muscle.
- C. Shake the vial of insulin vigorously before withdrawing the medication.
- D. Draw up clear insulin first when mixing two type of insulin in one syringe.
Correct Answer: D
Rationale: When mixing two types of insulin in one syringe, it is important to draw up the clear insulin first before drawing up the cloudy insulin. This is done to prevent contamination and ensure accurate dosing. Drawing up the clear insulin first helps to prevent the cloudy insulin from contaminating the clear insulin and maintains the proper ratio of each insulin type. It is an important technique to ensure the effectiveness and safety of insulin administration for the client.
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
- A. "A man should wear a latex condom during intimate sexual contact."
- B. "I've heard about people who got AIDS from blood transfusions."
- C. "I won't donate blood because I don't want to get AIDS."
- D. "IV drug users can get HIV from sharing needles."
Correct Answer: C
Rationale: It is important for the nurse to clarify to the student that donating blood does not put them at risk for getting AIDS. Blood donation centers follow strict protocols to ensure that donated blood is safe for transfusion, including screening for infectious diseases like HIV. It is admirable to donate blood as it can save lives without putting the donor at risk for acquiring HIV. It is crucial to dispel any misconceptions or fears surrounding blood donation to encourage people to participate in this important act of altruism.
The LPN is caring for a patient in the preoperative period who, even after verbalizing concerns and having questions answered, states, "I know I am not going to wake up after surgery." Which of the following actions should the nurse take?
- A. Reassure patient everything will be all right
- B. Explain national surgery death rate
- C. Inform the registered nurse
- D. Ask family to comfort the patient
Correct Answer: C
Rationale: The correct action for the LPN to take in this situation is to inform the registered nurse. The patient's statement indicates a high level of fear and anxiety about the surgery and their potential outcome. It is important to involve the registered nurse, who can provide further assessment, support, and interventions to address the patient's concerns appropriately. Simply reassuring the patient or providing statistics about national surgery death rates may not address the underlying fear and may require additional support and intervention. Asking the family to comfort the patient may not be the most appropriate immediate action as the patient's concerns are specific and may require professional support. Bringing the registered nurse into the situation allows for a comprehensive approach to addressing the patient's emotional needs before the surgery.
A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?
- A. Anticipatory grieving
- B. Disturbed body image
- C. Impaired swallowing
- D. Chronic low self-esteem
Correct Answer: A
Rationale: Anticipatory grieving is an appropriate nursing diagnosis for a client diagnosed with gallbladder cancer due to the nature of the diagnosis and the symptoms experienced. Gallbladder cancer carries a poor prognosis and can have a significant impact on the client's emotional well-being. The client may experience feelings of sadness, fear, and loss related to the cancer diagnosis and its implications on their health and future. The presence of symptoms such as yellow skin, weight loss, fatigue, and epigastric pain can further contribute to the client's distress and feelings of grief. As the client navigates the challenges associated with the cancer diagnosis and treatment, providing emotional support and assistance in coping with their feelings of anticipatory grief is essential for holistic care.