A client is experiencing epistaxis. Which of the following interventions would the nurse complete?
1. Call the doctor.
2. Check laboratory test results.
3. Obtain an emesis basin.
4. Show the patient how to pinch the nose.
4
The initial intervention for a client with epistaxis is to show the client how to lean forward and pinch the nose against the nasal septum for about 5 to 10 minutes continuously. The other interventions are not necessary at this time.
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A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?
a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.
is admitted to the emergency department after sustaining injury in a fall. Which assessment findings would the nurse immediately communicate to the emergency department physician?
1. The patient is taking a sulfa drug for urinary tract infection. 2. The patient has a bluish discoloration behind his ear. 3. The patient's nose is running. 4. The patient's smile is crooked. 5. The patient's tongue is lacerated.
Which is a suitable goal and expected outcome for a patient who is admitted for the recurrence of psychotic symptoms related to noncompliance with medication therapy?
a. Goal, safety; outcome, no risk for violence b. Goal, remission; outcome, symptom relief c. Goal, recovery; outcome, improved functioning d. Goal, rehabilitation; outcome, attain optimal quality of life
In a child with sickle cell anemia (SCA), adequate hydration is essential to minimize sickling and delay the vasooclusion and hypoxia-ischemia cycle. The nurse teaches the parents to:
a. encourage drinking. b. keep accurate records of output. c. check for moist mucous membranes. d. monitor the concentration of the child's urine.