Question 1

Providing a safe environment meets which need?

Accepted Answer

Answer reason: According to Maslow’s hierarchy, providing a safe environment addresses the safety and security level of needs. This includes protection from harm, injury, and infection and is foundational before higher-level psychosocial or self-fulfillment needs can be met. It is not related to self-actualization, esteem, or social belonging, which occur at higher levels once safety is ensured.

Question 2

Which site is avoided for intramuscular injection in infants?

Accepted Answer

Answer reason: The dorsogluteal site is avoided in infants because it carries a higher risk of sciatic nerve injury and the gluteal muscles are not well developed. Infants also have more variable subcutaneous fat thickness in this area, increasing the chance of improper needle placement. Preferred IM sites in infants are the vastus lateralis (most common) and, in some cases as age/size allow, the ventrogluteal because it is away from major nerves and vessels.

Question 3

Bedside confirmation of tube placement?

Accepted Answer

Answer reason: For bedside verification of nasogastric/feeding tube placement, aspirating gastric contents and testing pH is an accepted nursing method to reduce risk of inadvertent respiratory placement before using the tube. Pulse, blood pressure, and the ability to talk do not confirm gastric placement and can be normal even if the tube is malpositioned. While radiography is the gold standard for initial confirmation, among the choices provided the pH test is the safest and most specific bedside check.

Question 4

Which site is safest for intramuscular injection to avoid sciatic nerve injury?

Accepted Answer

Answer reason: The ventrogluteal site is considered the safest gluteal IM site because it is distant from the sciatic nerve and major blood vessels. In contrast, the dorsogluteal site is closer to the sciatic nerve and has a higher risk of nerve injury, so it is generally avoided. While the deltoid and vastus lateralis are also safe IM sites, the question specifically targets avoiding sciatic nerve injury, which is most relevant to choosing ventrogluteal over dorsogluteal.

Question 5

The most important step in the medication administration process is?

Accepted Answer

Answer reason: Correct patient identification is the key safety step that prevents administering a medication to the wrong person, which is a high-risk, preventable error. It directly supports the “right patient” component of safe medication administration and is required before giving any drug, regardless of preparation accuracy. Preparing the medication, documenting, and educating are important, but they do not mitigate the immediate, catastrophic risk of giving a drug to the wrong patient.

Question 6

A client is at risk for falls. What is the nurse's priority safety intervention?

Accepted Answer

Answer reason: Keeping the bed in the lowest position reduces the height of a potential fall and improves the client’s ability to safely get in and out of bed, directly lowering injury risk. Encouraging unassisted ambulation increases fall risk, and removing call lights prevents the client from summoning help. Turning off lights at night can worsen visibility and increase falls, so it is not a priority safety measure.

Question 7

What is the first step in routine blood collection?

Accepted Answer

Answer reason: The first step in routine blood collection is to correctly and positively identify the patient to prevent specimen mislabeling and wrong-patient errors. Patient identification (using appropriate identifiers per policy) must occur before selecting equipment, prepping the site, or labeling tubes. Although tubes must be labeled and correct equipment chosen, these steps are unsafe if performed before confirming the patient’s identity. This prioritizes error prevention and patient safety.

Question 8

An old woman was hit by motor cycle while crossing road, as a nurse the first intervention that she will provide is -?

Accepted Answer

Answer reason: The first priority in a roadside trauma is scene safety to prevent further harm to the client and rescuer. Moving the person to a safer place (only when necessary to avoid immediate danger such as traffic) helps stop ongoing exposure to injury. Immobilizing a limb and calling for help are important but come after ensuring the environment is safe and immediate hazards are controlled. Manually reducing a fracture is not a first-aid nursing priority and can worsen injury and neurovascular compromise.

Question 9

What type of fire can be put out with water?

Accepted Answer

Answer reason: Water is appropriate for Class A fires involving ordinary combustibles such as paper, wood, and cloth because it cools and penetrates the burning material. Water should not be used on electrical fires due to shock risk and potential equipment damage. It also should not be used on grease or many chemical fires because it can spread burning liquids or cause dangerous reactions. Therefore, the safest correct choice is paper.

Question 10

You exit a patient's room and hear a thud, finding them on the floor. What do you do FIRST?

Accepted Answer

Answer reason: After a fall, the priority is immediate assessment for injury and life-threatening problems (ABCs, bleeding, level of consciousness, obvious deformity, pain) before moving the patient. Moving the patient back to bed risks worsening a possible head, spine, or hip injury. Once the patient is assessed and stabilized, the nurse can call for help as needed and then obtain vital signs and notify the provider per protocol.

Question 11

During a surgical time-out, what must the nurse verify?

Accepted Answer

Answer reason: The surgical time-out is a required safety pause to prevent wrong-patient, wrong-site, and wrong-procedure events. The nurse must verify the patient’s identity, the correct surgical site (including laterality), and the planned procedure with the team using the consent and identifiers. While instrument readiness, sterility measures, and expected duration are important, they are not the defining required verification elements of the time-out. Therefore, confirming patient, site, and procedure is the single best answer.

Question 12

A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first?

Accepted Answer

Answer reason: The first nursing priority is safety for all clients and staff. Removing other clients from the immediate area reduces risk of injury and prevents escalation from audience effects while the RN begins de-escalation with the agitated client. Seclusion and chemical restraint are last-resort interventions used only when the client poses an imminent danger and less restrictive measures have failed; they also require appropriate orders and monitoring. Approaching with additional staff can be helpful, but ensuring bystander safety and reducing stimulation is the most immediate first action.

Question 13

Which scale assesses fall risk?

Accepted Answer

Answer reason: The Morse Fall Scale is specifically designed to quantify a patient’s risk of falling by scoring factors such as history of falling, secondary diagnoses, ambulatory aids, IV therapy, gait, and mental status. The Braden Scale assesses pressure injury (skin breakdown) risk, not falls. Glasgow Coma Scale measures level of consciousness, and APGAR evaluates newborn status immediately after birth. Therefore, the correct fall-risk assessment tool is the Morse Fall Scale.

Question 14

Nursing medication errors most commonly observed in hospitals are?

Accepted Answer

Answer reason: Across hospital settings, the most frequent medication administration errors involve incorrect dose calculations and IV infusion-rate programming, especially with high-alert medications delivered via pumps. These errors are more common than wrong-route or wrong-patient events because dosing and rate adjustments occur frequently and are prone to calculation, transcription, and pump-programming mistakes. Wrong drug and wrong patient errors are serious but typically less frequent due to barcode scanning and patient identification safeguards.

Question 15

Duration of each suction pass?

Accepted Answer

Answer reason: Each suction pass should be brief (generally no longer than about 10–15 seconds, and commonly taught as 5–10 seconds) to minimize hypoxemia, mucosal trauma, and vagal stimulation that can cause bradycardia. Longer suction times increase oxygen desaturation and airway injury risk. The safest standard practice among the options is the shortest time range.

Question 16

What common item can cause bed sore in ICU?

Accepted Answer

Answer reason: Wet linen increases moisture at the skin surface, leading to maceration and reduced skin integrity. Moisture also increases friction and shear during repositioning, which accelerates pressure injury formation in immobile ICU patients. Keeping bedding clean, dry, and wrinkle-free is a key prevention strategy. The other items listed are not common direct causes of pressure injuries compared with persistent moisture from wet linens.

Question 17

You are a phlebotomist and must draw a blood sample from a trauma patient in the emergency room. The patient has an IV in his left wrist and a cast on this right arm. Which of the following sites should be used to obtain blood for a glucose analysis?

Accepted Answer

Answer reason: Venipuncture should not be performed in an extremity with an active IV infusion because IV fluids/medications can contaminate the specimen and alter glucose results. The other arm is unavailable due to the cast, making standard antecubital or hand veins impractical or contraindicated. A capillary sample from an alternate site such as the earlobe can be used for glucose testing when upper-extremity venous access is not appropriate. Therefore, the earlobe is the best choice among the options.

Question 18

In the nursing care of a client with Meniere’s disease the nurse must teach the client ---?

Accepted Answer

Answer reason: Meniere’s disease causes episodic vertigo, imbalance, and possible sudden attacks, placing the client at high risk for falls and injury. Nursing teaching prioritizes safety strategies such as sitting or lying down during vertigo, avoiding driving/operating machinery during attacks, using assistive devices if needed, and fall-proofing the home. While avoiding tobacco, medication education, and general self-care can be helpful, preventing injury from acute vertigo is the most immediate and essential teaching focus.

Question 19

What is the first action in suspected spinal injury?

Accepted Answer

Answer reason: In suspected spinal injury, the priority first action is to immobilize the cervical spine and maintain spinal alignment to prevent secondary spinal cord damage. Movement can worsen an unstable fracture or convert a partial cord injury into a complete one. After immobilization, the nurse/first responder proceeds with ABCs, including oxygen and IV access as indicated. Pain management is addressed after stabilization and life-threatening risks are controlled.

Question 20

Raul, a 20-year-old student, used to buy OTC drugs whenever he felt sick. Which of the following statements best describes the danger of self-medication with over-the-counter drugs?

Accepted Answer

Answer reason: The primary danger of self-medicating with OTC drugs is that patients may assume they are inherently safe simply because they are sold without a prescription, leading to misuse (wrong dose, duplicate ingredients, prolonged use) and delayed evaluation of potentially serious conditions. This “false sense of safety” increases risk of adverse effects, contraindicated use with comorbidities, and dangerous drug–drug interactions. Option C best captures this overarching safety issue more completely than narrower statements about actions or side effects alone. Therefore, minimizing the significance of OTC medications due to easy access is the most accurate description of the risk.

Question 21

Safest method for checking NG tube placement?

Accepted Answer

Answer reason: Radiographic (X-ray) confirmation is the gold standard and safest method to verify initial NG tube placement because it definitively shows the tube tip location and helps prevent unrecognized tracheobronchial placement and aspiration. Air insufflation with auscultation is unreliable and can falsely suggest correct placement. Asking the patient is not a valid verification method, and aspirating gastric contents/pH testing can be helpful but is less definitive than an X-ray, especially in patients on acid-suppressing therapy.

Question 22

The nurse is responsible for maintaining which aspect of patient safety?

Accepted Answer

Answer reason: Patient safety most directly includes preventing injuries such as falls, which are a major, preventable cause of harm in healthcare settings. Nurses implement fall-risk assessments and interventions (e.g., call light within reach, non-skid footwear, bed in low position, assist with ambulation) to reduce accidents. Privacy and education are important nursing responsibilities, but they are more aligned with client rights and health promotion rather than the core safety hazard emphasized here.

Question 23

Best nursing intervention for a confused ambulatory client?

Accepted Answer

Answer reason: For a confused but ambulatory client, the priority is reducing risk of wandering and injury while supporting safe wayfinding. A picture on the door provides a clear visual cue that helps the client identify their room independently, which can decrease disorientation and unsafe roaming. Hourly reorientation is helpful but may be insufficient between contacts, and pinning a room number to clothing or using a colored wristband does not reliably help the client navigate safely.

Question 24

In which of the following locations would a NA stand when assisting a resident who has experienced a stroke to ambulate?

Accepted Answer

Answer reason: After a stroke, the affected side is weaker and at higher risk for giving way during ambulation. The nursing assistant should stand on the affected side to provide the strongest support, guard against falls, and control the gait belt if used. Standing behind or in front can interfere with balance and does not optimally protect the weak side. Guarding the affected side is a core fall-prevention strategy during assisted walking.

Question 25

Which of the following is an example of neglect?

Accepted Answer

Answer reason: Applying a restraint too tightly can impair circulation, cause skin breakdown, nerve injury, and pain, and represents unsafe care that fails to protect the client from harm. Improper restraint application is considered neglect/abuse because it involves failing to meet the standard of care and exposing the resident to preventable injury. The other options describe appropriate actions (prompt hygiene care, reporting appropriately, and seeking assistance) that support resident safety and care needs. Therefore, the best example of neglect is applying a restraint too tight.

Question 26

A nurse notes another staff member discarding sharps in the regular bin. What is the correct action?

Accepted Answer

Answer reason: Discarding sharps in a regular bin creates a serious needlestick and bloodborne-pathogen exposure risk. The safest and most professional response is to correct the unsafe practice through immediate education and ensure the event is managed through the facility’s reporting process so hazards are addressed and prevented. Ignoring the behavior fails to protect staff and patients, while simply reassigning avoids accountability and does not correct the system issue. Personally removing sharps from a regular bin increases exposure risk and is not the preferred first-line response compared with following established sharps-safety procedures.

Question 27

Which discharge teaching is most important for a client with a plaster cast on the arm?

Accepted Answer

Answer reason: A foul odor or localized warmth (“hot spots”) under a plaster cast can indicate infection, skin breakdown, or a pressure area that requires prompt assessment to prevent serious complications. Teaching the client to report these warning signs supports early intervention and helps prevent neurovascular and tissue compromise. The other options are unsafe or incorrect: the arm should generally be elevated (not kept below the heart) early to reduce swelling, inserting objects to scratch increases skin injury/infection risk, and using a hairdryer on a cast can cause burns and may not be appropriate guidance.

Question 28

Why is a systematic trauma approach important?

Accepted Answer

Answer reason: A systematic trauma approach (e.g., structured primary survey such as ABCDE) standardizes assessment and interventions so critical threats to life are identified and treated in the correct sequence. This reduces omissions, delays, and variability between providers, improving patient safety. It also supports clear communication and teamwork during high-stress emergencies. The approach is appropriate for all trauma severities, not only mass casualty events or severe cases.

Question 29

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Placing the call light within reach is a basic, evidence-based fall-prevention intervention that promotes timely assistance with toileting and mobility. Raising all four side rails can be considered a restraint and may increase injury risk if the client attempts to climb over them. Keeping the bed in a high position increases fall risk; the bed should be kept low and locked. Vest restraints are not first-line for fall prevention and require strict indications and monitoring due to safety and legal/ethical concerns.

Question 30

A patient is having a tonic-clonic seizure. A nurse should take which of the following steps?

Accepted Answer

Answer reason: During a tonic-clonic seizure, the priority is patient safety and injury prevention. Placing something soft under the head helps prevent head trauma from uncontrolled movements. Restraints can cause musculoskeletal injury, and nothing should be placed in the mouth (e.g., tongue blade) due to aspiration and dental injury risk. The patient should be turned to a side-lying position to maintain airway and reduce aspiration risk, so laying the patient on the back is not recommended.

Question 31

The best way to safely identify your patient is by?

Accepted Answer

Answer reason: The safest standard approach is to use an active identifier by asking the patient to state their identity and confirming it, which reduces wrong-patient errors. Simply asking a yes/no question like "Are you Mr. X?" or relying on passive indicators increases the risk of misidentification. Bed plates can be incorrect or outdated and should not be used as the primary identifier. A name tag/ID band is important to verify, but the best option given emphasizes patient participation to confirm identity rather than relying on environmental labels.

Question 32

A client in labor is receiving an oxytocin infusion. Which assessment requires immediate intervention?

Accepted Answer

Answer reason: Oxytocin can cause uterine tachysystole/hyperstimulation, reducing uteroplacental perfusion and leading to fetal hypoxia. Contractions lasting 90 seconds are concerning because prolonged contractions allow inadequate uterine relaxation time, increasing risk for fetal distress and uterine rupture. The other findings are expected/normal in labor: FHR 145 with moderate variability is reassuring, BP 110/70 is normal, and 5 cm dilation indicates labor progress.

Question 33

The nurse teaches a client with a leg cast. Which statement requires follow-up?

Accepted Answer

Answer reason: Using a stick or other object to scratch inside a cast can cause skin breakdown, abrasions, and pressure injury that the client may not see or feel well. It also increases risk of introducing bacteria, leading to infection under the cast. The other statements reflect correct cast care: monitoring for odor/drainage (possible infection), elevating to reduce swelling, and keeping the cast dry to maintain integrity and prevent skin maceration.

Question 34

Which is the best site for IM injection in infants under 1 year?

Accepted Answer

Answer reason: For infants under 12 months, the vastus lateralis (anterolateral thigh) is the preferred IM injection site because it is well developed and has fewer major nerves and blood vessels at risk. The gluteus maximus is avoided due to poor muscle development and risk of sciatic nerve injury. The deltoid is typically reserved for older children when adequate muscle mass is present. Rectus femoris is more painful and is not the first-choice site compared with vastus lateralis.

Question 35

What is the best way to confirm correct placement of a nasogastric (NG) tube?

Accepted Answer

Answer reason: Radiographic confirmation is the gold standard for verifying NG tube placement, especially before initiating enteral feeding or administering medications. Methods like auscultating an air bolus (“whoosh test”) are unreliable and can miss respiratory placement, increasing aspiration and pneumothorax risk. Patient ability to talk or subjective reporting cannot rule out malposition. Therefore, an X-ray is the safest and most accurate confirmation.

Question 36

A nurse plans care for a client with growth hormone deficiency. Which action should the nurse include in this client’s plan of care?

Accepted Answer

Answer reason: Growth hormone deficiency in children is commonly associated with short stature and delayed skeletal development, increasing risk for musculoskeletal injury. Using a lift sheet helps minimize shear and traction forces during repositioning, promoting safety and preventing injury. The other options do not specifically address a key nursing safety need for growth hormone deficiency (no indication for protective isolation, orthostatic precautions, or avoiding IM injections). Therefore, a lift sheet for repositioning is the best plan-of-care action.

Question 37

SITUATION : Knowledge of the drug propantheline bromide [Probanthine] is necessary in treatment of various disorders. Q. What should the nurse caution the client when using this medication?

Accepted Answer

Answer reason: Propantheline is an anticholinergic agent that can cause adverse effects such as blurred vision, dizziness, and drowsiness, which increase risk for injury. Teaching should emphasize avoiding driving or operating machinery until the patient knows how the medication affects them. The option about doubling a missed dose is unsafe and incorrect medication practice. While anticholinergics may be taken before meals, the primary nursing caution among the choices is safety with activities requiring alertness and clear vision.

Question 38

A side effects or a complication of medicine is ...?

Accepted Answer

Answer reason: An adverse drug event (ADE) is harm experienced by a patient related to a medication, and it includes side effects and other medication-related complications. A drug error and a near miss describe failures in the medication-use process and may or may not result in patient harm. A drug overdose is one possible cause of an ADE, but it is narrower than the concept of medication side effects/complications.

Question 39

A child is scheduled for a tonsillectomy. Which should present the highest risk of aspiration during surgery?

Accepted Answer

Answer reason: The presence of loose teeth. Loose teeth can be dislodged during airway instrumentation (e.g., laryngoscopy/intubation) and become a foreign body that may be aspirated into the tracheobronchial tree. This is a direct perioperative safety hazard and requires preoperative identification and precautionary measures. The other options relate more to symptoms/operative issues but are less likely to cause aspiration of a solid object during anesthesia compared with a dislodged tooth.

Question 40

The nurse administered the wrong IV antibiotic to a post-op client. What is the priority nursing action?

Accepted Answer

Answer reason: Assess the client for adverse reactions. After a medication error, the immediate priority is client safety using ABCs and rapid assessment for any signs of harm (e.g., allergy/anaphylaxis, infusion reaction, hemodynamic instability). Assessing the client first determines whether urgent interventions are needed before further actions. Notifying the provider and completing an incident report are important, but they occur after ensuring the client is stable. Administering the “correct” antibiotic is not the first step because the client must be evaluated and the prescriber notified for further orders based on the error and client status.

Question 41

Acetaminophen Overdose and Drug-Induced Liver Injury A conscious and alert 22-year-old female is rushed to the emergency room 30 minutes after ingesting half a bottle of acetaminophen at home. Which among the following initial management techniques should be done after getting a quick history?

Accepted Answer

Answer reason: Administer activated charcoal Within 30 minutes of a large acetaminophen ingestion in an alert patient with a protected airway, activated charcoal is appropriate early GI decontamination and can reduce drug absorption if given within 1–2 hours. Gastric lavage is rarely indicated and generally reserved for very severe, life-threatening ingestions when performed very soon after ingestion. N-acetylcysteine is the antidote for acetaminophen toxicity, but the initial management in this time window is charcoal while labs/acetaminophen level and risk assessment are initiated; NAC is started based on toxic dose, timing, or nomogram/level criteria. Cholestyramine is not a treatment for acetaminophen overdose.

Question 42

A nurse enters a patient’s room and finds the patient lying on the floor. What is the first action the nurse should take?

Accepted Answer

Answer reason: The nurse’s first priority after finding a patient on the floor is immediate assessment for injury and life-threatening issues (ABCs, level of consciousness, pain, bleeding, suspected fracture/head injury). This guides whether to call a rapid response, keep the patient immobile, and initiate urgent interventions. Calling the provider, asking what happened, and documenting are important but come after the initial safety assessment and stabilization.

Question 43

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

Accepted Answer

Answer reason: With a halo vest, the sheepskin/lamb's-wool liner should generally be kept clean and dry, and the client should not remove or lift the vest/liner to wash underneath because this can compromise immobilization and lead to skin breakdown or infection. Skin care focuses on inspecting accessible skin, keeping the vest/liner dry, and reporting irritation, odor, drainage, or hot spots to the provider. The other statements reflect appropriate safety and self-care measures while adapting to restricted head/neck movement and altered balance.

Question 44

Which of the following is a priority action when a patient falls?

Accepted Answer

Answer reason: Assess for injuries After a fall, the nurse’s first priority is to assess the patient for injuries (ABCs, level of consciousness, pain, deformity, bleeding) before moving them, to avoid worsening a possible fracture or head/neck injury. Documentation and notifying the provider are important but occur after immediate assessment and stabilization. Administering pain medication is not appropriate until injuries are assessed and the cause of pain is better understood, and it can mask symptoms needed for evaluation.

Question 45

The best way to confirm NG tube placement is by auscultation?

Accepted Answer

Answer reason: False Auscultation (“whoosh test”) is not a reliable method to verify nasogastric tube placement and can miss dangerous malposition (e.g., in the respiratory tract). The most accurate confirmation is radiographic (x-ray) verification, especially for initial placement, before using the tube for feeding/medications. Ongoing checks may include aspirating gastric contents and assessing pH per facility policy, but auscultation should not be considered the best method.

Question 46

Receiving oxygen therapy via nasal cannula at 2 L/min. Which of the following actions by the nurse demonstrates proper oxygen safety precautions?

Accepted Answer

Answer reason: Placing an “Oxygen in Use” sign on the patient’s door. Oxygen supports combustion, so clear signage alerts staff and visitors to avoid ignition sources (e.g., smoking, open flames) and to follow facility oxygen precautions. Petroleum-based products like petroleum jelly are flammable and should be avoided; use water-based lubricants instead. Visitors should never smoke near oxygen, and adjusting prescribed oxygen flow without an order is unsafe and outside standard practice (except per protocol).

Question 47

A nurse should always check a patient’s identity before administering medication?

Accepted Answer

Answer reason: True Verifying patient identity is a core medication-safety step that prevents wrong-patient medication errors. Standard practice is to use at least two identifiers (e.g., name and date of birth) and match them to the medication administration record and wristband. This check is performed every time, even if the nurse knows the patient, because handoffs and room changes can occur.

Question 48

A nurse should always use restraints as the first option for managing an agitated patient?

Accepted Answer

Answer reason: False Restraints are an intervention of last resort because they can cause physical injury, psychological trauma, and escalation of agitation, and they restrict a patient’s rights. Initial management should prioritize least-restrictive measures such as verbal de-escalation, addressing pain/hypoxia/hypoglycemia, modifying the environment, and using close observation. If restraints are required for immediate safety, they must follow policy and legal/ethical standards, include ongoing monitoring, and be discontinued as soon as possible.

Question 49

After a client has experienced a seizure, what is the most appropriate position in which the nurse should place the client?

Accepted Answer

Answer reason: On the side Side-lying positioning after a seizure helps maintain a patent airway by allowing saliva or emesis to drain and reduces the risk of aspiration. The postictal period commonly includes decreased level of consciousness and impaired protective reflexes, so airway protection is the immediate priority. Supine positioning increases the likelihood of tongue obstruction and pooling of secretions, while prone or sitting upright can compromise breathing or safety in an unresponsive client.

Question 50

A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

Accepted Answer

Answer reason: Pinch the soft lower part of the nose for a minimum of 5 minute Direct pressure to the soft anterior portion of the nose compresses Kiesselbach’s plexus, the most common source of epistaxis, and is the most effective immediate nursing action to control bleeding. The client should be kept leaning slightly forward to avoid swallowing blood and to help assess ongoing bleeding. Hyperextending the head increases blood flow into the pharynx and aspiration risk, while tight packing is not a first-line nursing measure and can further traumatize tissue in a client with impaired coagulation. Cold therapy may be an adjunct but is not as reliably effective as sustained direct pressure.

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