The nurse is caring for a hospitalized older patient who has ...

[wrbasek0]

The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse?
 
  a. The oxygen saturation is 89.
  b. The nose appears red and swollen.
  c. The patient's temperature is 100.1 F (37.8 C).
  d. The patient complains of level 8 (0 to 10 scale) pain.

Question 2

After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?
 
  a. Clear nasal drainage
  b. Complaint of nasal pain
  c. Bilateral nose swelling and bruising
  d. Inability to breathe through the nose

[Tonny]

Answer to Question 1

ANS: A
Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89 should alert the nurse to further assess for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the low O2 saturation.

Answer to Question 2

ANS: A
Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications.