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

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.

Correct Answer: A

Rationale: Thalassemia is a genetic blood disorder that results in the reduced production of hemoglobin and red blood cells. Nursing interventions for a client with thalassemia aim to manage symptoms and prevent complications. Maintaining the client on bed rest helps conserve energy and prevent fatigue, which is commonly experienced due to anemia. Protecting the client from infections is crucial because individuals with thalassemia are at a higher risk of infections due to their weakened immune system. By minimizing the risk of infections, nurses can help prevent further complications in clients with thalassemia.

Correct Answer: A

Rationale: Following a splenectomy (spleen removal), patients are at an increased risk of developing infections, particularly those caused by encapsulated bacteria such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis. The spleen plays a vital role in the immune system by filtering and clearing bacteria and viruses from the bloodstream. Without a functioning spleen, patients are more vulnerable to bacterial infections. Therefore, the nurse should be aware of the potential for infection and provide appropriate education to the client regarding infection prevention strategies, such as vaccinations and prompt medical treatment for any signs of infection.

Correct Answer: B

Rationale: When applying a new system for pain management, it is recommended to choose a site on the lower torso. This area is often a suitable location for applying transdermal pain medication patches because it tends to have fewer hair follicles, making it easier for the patch to adhere properly and be absorbed effectively. The lower torso also typically provides a discreet location for patch placement, helping to maintain patient privacy and comfort.

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.