NCLEX-PN® ExaminationPhysiological AdaptationMedium
A client is experiencing severe epistaxis that has not responded to direct pressure. The nurse notes the client is becoming increasingly anxious, and blood is trickling down the back of the throat. Which of the following is the most appropriate next nursing action?
- APrepare for nasal packing or cauterization.
- BInstruct the client to lie flat and tilt the head back.
- CApply ice packs to the client's forehead.
- DAdminister an oral anti-anxiety medication.
Show answer & explanationAnswer & explanation
Correct answer: A. Prepare for nasal packing or cauterization.
Severe epistaxis unresponsive to direct pressure, with blood trickling down the throat, indicates a posterior nosebleed or a persistent anterior bleed. This requires more aggressive interventions like nasal packing or chemical/electrical cauterization, often performed by a medical provider. The nurse's role is to anticipate and prepare for these interventions.
Why the other options are wrong
- B. Lying flat and tilting the head back can cause blood to drain into the pharynx, increasing the risk of aspiration and making it difficult to assess blood loss. The client should sit upright and lean forward.
- C. Ice packs to the forehead are not effective for severe, persistent epistaxis.
- D. While the client is anxious, controlling the bleeding is the immediate priority. Anti-anxiety medication can be considered after the bleeding is managed.
Severe Epistaxis Management
Management of severe epistaxis (nosebleed) unresponsive to direct pressure involves more advanced interventions such as nasal packing or cauterization to stop persistent bleeding.
- Initial management is direct pressure for 10-15 minutes, leaning forward.
- Persistent bleeding, especially posterior, requires medical intervention.
- Aspiration risk is a concern if blood drains posteriorly.
Memory trick: Pack the nose when pressure's failed, a bloody crisis now assailed!