Special Situations: Epistaxis, Anticoagulants, Pregnancy, Children, and Older Adults Practice Questions

25 multiple-choice questions on Special situations: epistaxis, anticoagulants, pregnancy, children, and older adults for paramedic and EMT students, from Chapter 31 (Bleeding). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A man had a tooth pulled this morning and the socket keeps oozing blood. He is alert and stable. The best first measure is to:

   1. A. Rinse his mouth hard and often with water
   2. B. Have him bite firmly on folded gauze
   3. C. Pack the socket with a cotton-tipped swab
   4. D. Have him lie flat with his head turned back
   Show answer

   Answer: B. Have him bite firmly on folded gauze

   Firm, sustained pressure from biting on a gauze pad placed over the socket (for about 30 minutes) controls most post-extraction bleeding. Vigorous rinsing dislodges the clot, a swab gives poor pressure and may be aspirated, and lying flat with the head back lets blood run into the airway.

2. A 19-year-old has deep self-inflicted cuts to the forearm that are bleeding steadily. After controlling the bleeding, the most important next consideration is:

   1. A. Assessing suicide risk and her safety
   2. B. Letting her leave if the bleeding stops
   3. C. Checking her blood glucose level
   4. D. Irrigating the cuts with saline
   Show answer

   Answer: A. Assessing suicide risk and her safety

   Bleeding control comes first, but self-harm requires a safety assessment: ask directly about suicidal intent, remove means, do not leave her alone, and transport for evaluation. A stopped bleed does not end the risk. Glucose checks and wound irrigation are reasonable care, but neither addresses the immediate danger to her life.

3. You apply a commercial tourniquet high on the very large thigh of a 180-kg man, but the bleeding does not stop even with the windlass tightened fully. You should:

   1. A. Loosen it and rely on direct pressure
   2. B. Add a second one just above the first
   3. C. Move it below the wound and tighten it
   4. D. Accept the bleeding until the hospital
   Show answer

   Answer: B. Add a second one just above the first

   Large limbs may need more than one tourniquet to occlude arterial flow. Place a second tourniquet just above the first (proximal), then reassess. Loosening the tourniquet or relying on pressure alone wastes time, a tourniquet below the wound will not stop arterial inflow, and ongoing bleeding must never be accepted.

4. A hospice patient with a large ulcerating neck tumor has steady bleeding from the tumor surface. His care plan focuses on comfort. You should:

   1. A. Transport emergently to a trauma center
   2. B. Start two large-bore IVs for fluids
   3. C. Use gentle pressure and dark towels
   4. D. Pack the wound tightly to the base forcefully
   Show answer

   Answer: C. Use gentle pressure and dark towels

   A comfort-focused plan still includes bleeding control. Gentle pressure with dressings (hemostatic dressings if available) and dark towels to reduce the visual distress of bleeding are appropriate, while contacting hospice per the care plan. Emergent trauma transport and aggressive IV resuscitation conflict with a comfort-focused plan, and forceful packing of a tumor causes pain and more bleeding.

5. Patients with an anterior nosebleed are told not to swallow the blood mainly because swallowed blood:

   1. A. Is directly toxic to the liver
   2. B. Raises the blood pressure
   3. C. Thins the remaining blood
   4. D. Causes nausea and vomiting
   Show answer

   Answer: D. Causes nausea and vomiting

   Blood irritates the stomach and causes vomiting, which can restart bleeding and risks aspiration. Swallowing also hides how much blood is being lost.

6. A 15-year-old has a nosebleed after an elbow to the face during basketball. Besides bleeding control, you should assess for:

   1. A. A hypertensive emergency as the cause
   2. B. An acute sinus infection
   3. C. An inherited bleeding disorder
   4. D. Facial fractures and head injury
   Show answer

   Answer: D. Facial fractures and head injury

   Traumatic epistaxis can accompany nasal, orbital, or midface fractures and head injury, which need evaluation. Hypertension and bleeding disorders are considered in spontaneous nosebleeds, not one clearly caused by a blow.

7. An 81-year-old on warfarin has a forearm skin tear that keeps oozing despite a dressing. You should:

   1. A. Hold pressure longer, then use a pressure dressing
   2. B. Apply a tourniquet before trying any direct pressure
   3. C. Leave it uncovered so it can clot in the air
   4. D. Give her vitamin K by mouth before transport
   Show answer

   Answer: A. Hold pressure longer, then use a pressure dressing

   Anticoagulated patients form clots slowly, so pressure must be held longer and then maintained with a pressure dressing. A tourniquet is reserved for life-threatening limb bleeding, and reversal is a hospital decision.

8. A tourniquet remains effective in a patient taking anticoagulants because it:

   1. A. Reverses the effect of the drug
   2. B. Activates the patient's own platelets
   3. C. Mechanically stops arterial inflow
   4. D. Speeds up the clotting cascade
   Show answer

   Answer: C. Mechanically stops arterial inflow

   Tourniquets work by compression, not by clotting, so anticoagulation does not reduce their effect. Hemostatic dressings that depend on the clotting cascade may be less effective in these patients.

9. A bleeding trauma patient takes an anticoagulant. The most useful information to relay to the hospital is the:

   1. A. The reason it was first prescribed
   2. B. Drug name and time of the last dose
   3. C. The name of the prescribing doctor
   4. D. Color and shape of the tablets she takes
   Show answer

   Answer: B. Drug name and time of the last dose

   Reversal differs by drug (vitamin K and prothrombin complex for warfarin, idarucizumab for dabigatran, andexanet or PCC for factor Xa inhibitors), and timing shows whether the drug is still active. The indication and prescriber can be found later, and pill appearance does not guide reversal.

10. Two days after knee surgery, a patient's surgical dressing is soaked with blood and it is still oozing. He is alert with normal vital signs. The best initial action is to:

    1. A. Reinforce the dressing and press
    2. B. Remove the dressing to inspect the incision
    3. C. Apply a tourniquet above the knee at once
    4. D. Leave it alone, since some ooze is normal
    Show answer

    Answer: A. Reinforce the dressing and press

    Bleeding from a recent surgical site is managed like any other wound: leave the original dressing in place, add dressings, and hold firm pressure, then transport and tell the hospital which surgery was done and whether he takes anticoagulants (often prescribed after joint replacement). Removing the dressing disrupts clot, a tourniquet is for life-threatening bleeding, and a soaked dressing is not normal.

11. A woman 32 weeks pregnant was in a moderate-speed crash. She has abdominal pain, HR 96, and BP 112/70 mmHg. Why should you treat her as possibly hypovolemic?

    1. A. Pregnancy normally causes a slow heart rate
    2. B. Her blood volume is lower than before pregnancy
    3. C. Uterine flow may drop before her vitals change
    4. D. Her blood pressure is higher than normal
    Show answer

    Answer: C. Uterine flow may drop before her vitals change

    Maternal compensation shunts blood away from the uterus to protect her own vital signs, so fetal distress can come first. Pregnancy normally raises the heart rate by 10 to 15 beats/min, which can mask early shock.

12. A cold, wet crash victim's forearm laceration was barely bleeding at the scene. Ten minutes after being warmed in the ambulance, it begins to bleed briskly. The most likely reason is:

    1. A. The dressing material is now too warm
    2. B. Vasoconstriction eased as he warmed
    3. C. Warmth has caused his clotting to fail
    4. D. A new injury occurred during the move
    Show answer

    Answer: B. Vasoconstriction eased as he warmed

    Cold causes intense skin vasoconstriction that can hide bleeding. As the patient warms, vessels dilate and the wound may bleed again, so reassess dressings after rewarming. Warming actually improves clotting, the dressing temperature is irrelevant, and nothing suggests a new injury.

13. A man who had a coronary stent placed 2 months ago takes aspirin and clopidogrel. He has a cut finger that oozes but is controlled with pressure, and he asks whether he should stop his clopidogrel. You should advise him to:

    1. A. Stop it at once to prevent more bleeding
    2. B. Stop the aspirin but keep the clopidogrel going
    3. C. Double the dose to protect the new stent
    4. D. Keep taking it and ask his cardiologist
    Show answer

    Answer: D. Keep taking it and ask his cardiologist

    Stopping dual antiplatelet therapy soon after a stent carries a high risk of stent thrombosis and heart attack, so he should keep taking it and let the prescribing cardiologist decide on any change. A minor oozing wound is managed with longer pressure and a pressure dressing. Stopping it at once to prevent more bleeding, stopping the aspirin, or doubling the dose on his own are all unsafe.

14. A woman delivered 15 minutes ago and is bleeding heavily with a soft, boggy uterus. In addition to fundal massage, TXA may be given as:

    1. A. 2 g IM in the deltoid
    2. B. 100 mg IV push
    3. C. 1 g orally every 8 hours
    4. D. 1 g IV over 10 minutes
    Show answer

    Answer: D. 1 g IV over 10 minutes

    The WOMAN trial showed that 1 g of TXA IV within 3 hours of birth reduces death from postpartum hemorrhage; a second gram may be given if bleeding continues. Fundal massage and breastfeeding promote uterine contraction.

15. A 4-year-old boy was struck by a car. His systolic pressure is 72 mmHg. This is:

    1. A. Normal for a 4-year-old
    2. B. Hypotensive for his age
    3. C. Elevated for a 4-year-old
    4. D. Low only if he is also pale
    Show answer

    Answer: B. Hypotensive for his age

    For ages 1 to 10, hypotension is a SBP below 70 + (2 × age), here 78 mmHg. In children, hypotension is a late sign that follows substantial blood loss.

16. A 6-year-old with a femur fracture is pale, with HR 150 and a normal blood pressure. This means:

    1. A. He is in compensated shock
    2. B. He is stable since his BP is normal
    3. C. His tachycardia is from fear alone
    4. D. He is in irreversible shock
    Show answer

    Answer: A. He is in compensated shock

    Children maintain blood pressure through tachycardia and vasoconstriction until they lose a large share of their volume, then decompensate suddenly. A normal BP in a pale, tachycardic child is not reassuring.

17. A 5-year-old has spurting arterial bleeding from a deep thigh laceration. Regarding a commercial tourniquet, you should:

    1. A. Avoid it, as tourniquets harm children
    2. B. Use only an elastic bandage
    3. C. Apply it, as it can work on children
    4. D. Apply it only after direct pressure fails
    Show answer

    Answer: C. Apply it, as it can work on children

    Commercial windlass tourniquets have been shown to occlude arterial flow in children's limbs, and life-threatening bleeding in a child is treated as in an adult. If the limb is too small for the tourniquet to tighten, use firm pressure and packing.

18. A home-care patient's central venous catheter in the neck was accidentally pulled out, and the site is bleeding. The best immediate action is to:

    1. A. Leave the site open to drain the blood
    2. B. Sit the patient up while you find gauze
    3. C. Push the catheter back into the vein
    4. D. Seal with an occlusive dressing, press
    Show answer

    Answer: D. Seal with an occlusive dressing, press

    When a central line in the neck or chest is pulled out, the open tract can bleed and entrain air, causing air embolism. Cover the site with an occlusive dressing, hold firm pressure, and keep the patient supine (or head down if tolerated). Sitting up raises the risk of air entry, the catheter must never be reinserted, and the site should not be left open.

19. Under the 2021 field triage guideline, for a patient 65 or older, a systolic pressure below what value is a high-risk criterion?

    1. A. 70 mmHg
    2. B. 110 mmHg
    3. C. 80 mmHg
    4. D. 90 mmHg
    Show answer

    Answer: B. 110 mmHg

    Older adults often have baseline hypertension, so an SBP that looks normal may represent shock. The guideline uses SBP under 110 mmHg for age 65 and older and under 90 mmHg for younger adults.

20. A man fell and struck his head. Blood-tinged fluid is draining from his right ear. You should:

    1. A. Pack the ear canal firmly to stop the drainage
    2. B. Irrigate the ear with sterile saline
    3. C. Cover the ear loosely with sterile gauze
    4. D. Apply firm pressure over the ear canal
    Show answer

    Answer: C. Cover the ear loosely with sterile gauze

    The drainage may contain CSF from a basilar skull fracture; blocking it could raise intracranial pressure and increase infection risk. A loose dressing absorbs the fluid without stopping its flow.

21. Blood from a patient's ear leaves a red center surrounded by a lighter ring on a gauze pad. This finding suggests:

    1. A. Cerebrospinal fluid mixed with blood
    2. B. Infection of the middle ear
    3. C. Bleeding from the outer ear canal only
    4. D. A ruptured eardrum from pressure
    Show answer

    Answer: A. Cerebrospinal fluid mixed with blood

    The halo or target sign occurs because CSF spreads farther on the gauze than blood. It is not specific, but it supports a basilar skull fracture, as do Battle sign and raccoon eyes.

22. A patient on hemodialysis has brisk bleeding from his arm fistula that firm direct pressure has not controlled. You should:

    1. A. Apply a tourniquet above the fistula
    2. B. Clamp the fistula with a hemostat
    3. C. Elevate the arm and recheck in 10 minutes
    4. D. Apply ice and a loose wrap
    Show answer

    Answer: A. Apply a tourniquet above the fistula

    A fistula carries arterial flow and can cause fatal bleeding quickly. If firm pressure fails, a tourniquet is appropriate even though it may threaten the access; clamping with a hemostat can damage the vessel and is not recommended.

23. A patient with lung cancer is coughing up large amounts of bright red blood, and you suspect it is from the right lung. You should position him:

    1. A. On his left side
    2. B. Supine and flat
    3. C. On his right side
    4. D. Prone with arms raised
    Show answer

    Answer: C. On his right side

    Placing the bleeding lung down keeps blood from spilling into the healthy lung. Suction and airway readiness are critical, because massive hemoptysis kills by asphyxiation more often than by blood loss.

24. A patient is vomiting large amounts of bright red blood and has a decreasing level of consciousness. Your first priority is to:

    1. A. Start a second large-bore IV line
    2. B. Obtain orthostatic vital signs
    3. C. Give oral fluids to replace losses
    4. D. Suction and protect his airway
    Show answer

    Answer: D. Suction and protect his airway

    Aspiration of blood is the immediate threat, so suction, lateral positioning, and airway management come first. IV access is important but follows; orthostatic vital signs are unnecessary and unsafe here.

25. A 90-year-old with a valid DNR order has a deep arm laceration that is spurting blood. Regarding bleeding control, you should:

    1. A. Withhold all care because of the DNR
    2. B. Control it; a DNR does not forbid it
    3. C. Only provide care if the family agrees
    4. D. Ask medical control before any pressure
    Show answer

    Answer: B. Control it; a DNR does not forbid it

    A DNR order applies to cardiopulmonary resuscitation if the patient is in arrest; it does not forbid treatment of a bleeding wound, pain, or other conditions. Control the bleeding with pressure or a tourniquet and treat according to the patient's wishes. Withholding care, waiting for family, or delaying for an order would let a treatable bleed become fatal.