A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by
a) Instructing the client to tilt the head back with ice applied to the nose
b) Applying pressure to the nose for 1 to 2 minutes
c) Pinching the upper and hard portion of the nose
d) Telling the client to sit upright with the head tilted forward
Answer: d) Telling the client to sit upright with the head tilted forward
Explanation:
Hemorrhage or massive bleeding from the nose is called epistaxis. Initial interventions include having the client sit upright with the head tilted forward to prevent swallowing and aspiration of blood. Tilting the head back will encourage the client to swallow and possibly aspirate blood. Pressure is applied to the soft outer portion of the nose against the midline septum, not the upper and hard portion of the nose. Pressure is also applied continuously for 5 to 10 minutes. pg.555
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