Question 1 of 6
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Which intervention would the nurse include when caring for a patient with epistaxis who is to be taken for x-rays of the skull and face? Select all that apply. One, some, or all responses may be correct.
- Correct
- Monitoring airway patencyAirway patency is always the priority.
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- Administering a narcotic analgesicIn general, analgesia is held until a diagnosis can be made, and it is determined whether surgery will be necessary.
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- Keeping the patient sitting forwardKeeping the patient sitting forward prevents blood from running down the back of the throat.
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- Encouraging the patient to take sips of waterIn general, oral intake is held until a diagnosis can be made, and it is determined whether surgery will be necessary.
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- Compressing the bleeding nostril against the septum and applying iceCompression of the nostril and application of ice to the area are standard actions to control epistaxis.
Question 2 of 6
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Which action would be taken by the nurse caring for a patient who has bleeding from the nose that began approximately 30 minutes ago?
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- Having the patient bend his head backWhen epistaxis occurs, the patient should sit forward (not bend the head back) and apply direct pressure by pinching the nose just below the bone, close to the face, for 10 to 15 minutes.
- Correct
- Applying direct pressure for 10 to 15 minutesWhen epistaxis occurs, the patient should sit forward (not bend the head back) and apply direct pressure by pinching the nose just below the bone, close to the face, for 10 to 15 minutes. This position prevents blood from running down the back of the throat.
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- Applying a warm compress to the nose to constrict blood vesselsCold compresses or ice (not warm compresses) may be applied to the nose to constrict the blood vessels.
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- Removing the towel from the nose to see the extent of blood lossIf there is still bleeding at the end of a 10- to 15-minute period, the nurse would repeat the process. Gloves would be donned with any contact of blood or body secretions. Removing the towel at this time may remove the pressure that is stopping a larger hemorrhage. The nurse would reinforce the area with gauze sponges and notify the health care provider of the situation.
Question 3 of 6
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Which patient behavior may indicate bleeding at the operative site after a tonsillectomy?
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- Frequent swallowingAs blood runs down the throat, the patient will frequently swallow.
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- Refusal to lie on the sideRefusing to lie on the side does not indicate bleeding.
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- Complaints of throat painThroat pain is expected and does not necessarily indicate bleeding.
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- Seeming frightened when moving the neckBeing frightened when moving the neck does not indicate bleeding.
Question 4 of 6
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Which medication might be prescribed to treat allergic rhinitis and sinusitis? Select all that apply. One, some, or all responses may be correct.
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- CetirizineCetirizine is an antihistamine that helps relieve sneezing, secretions, itching, and nasal congestion. This might be prescribed to treat allergic rhinitis and sinusitis.
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- FluticasoneFluticasone is a corticosteroid spray that helps to decrease swelling and relieve a runny nose and sneezing. This might be prescribed to treat allergic rhinitis and sinusitis.
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- DiphenhydramineDiphenhydramine is an antihistamine that helps relieve sneezing, secretions, and congestion. This might be prescribed to treat allergic rhinitis and sinusitis.
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- AmoxicillinAmoxicillin is a penicillin antibiotic that fights bacterial infections. It would not be indicated for rhinitis and sinusitis.
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- AlbuterolAlbuterol is a bronchodilator used to prevent bronchospasms in patients with breathing problems because of asthma, lung disease, or bronchitis.
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- AzelastineAzelastine is an H1-receptor antagonist used to help relieve nasal congestion. This might be prescribed to treat allergic rhinitis and sinusitis.
Question 5 of 6
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Which statement made by the patient indicates a need for further teaching?
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- “I will stay indoors and rest the first few days of my cold.”It is important for the patient to stay indoors, either in bed or resting, during the first few days they are ill.
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- “I will wash my hands every time I sneeze to avoid spreading my cold to others.”Colds are spread by droplet infection and can spread during coughing or sneezing. Hand hygiene is important to prevent spread.
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- “I will decrease my fluid intake to prevent secretions from building up.”The patient should increase fluids to help thin out secretions.
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- “I can use my nasal spray for the first 3 days.”Decongestants, nasal drops, and nasal sprays can be used for no more than 3 days; otherwise, the patient can develop rebound symptoms and worsening congestion.
Question 6 of 6
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Which diagnosis would the nurse anticipate for a patient with tonsillitis caused by the Epstein-Barr virus?
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- Infectious mononucleosisTonsillitis caused by the Epstein-Bass virus is called glandular fever or infectious mononucleosis.
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- GlomerulonephritisGlomerulonephritis is inflammation and damage to the filtering portion of the kidneys, the glomerulus. Streptococcus can lead to glomerulonephritis if not treated properly.
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- EpistaxisEpistaxis is a nosebleed and a common occurrence when there is crusting, cracking, or irritation of the mucous membranes covering the anterior portion of the nasal septum.
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- MeningitisMeningitis is an infection in the fluid surrounding the brain and spinal cord. It can be a complication of sinus infections.
