A nurse is assessing a child who is 2 hours postoperative following a cardiac catheterization and finds the dressing is saturated with blood.
Which of the following actions should the nurse take first?
Reinforce the dressing.
Apply pressure just above the insertion site.
Obtain vital signs.
Monitor the pulse distal to the insertion site.
The Correct Answer is B
The correct answer is Choice B.
Choice A rationale
Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority. Applying pressure just above the insertion site is the first step to control bleeding and prevent further blood loss.
Choice B rationale
Applying pressure just above the insertion site is the first step to control bleeding and prevent further blood loss. This action helps to stop the bleeding and stabilize the patient.
Choice C rationale
Obtaining vital signs is important, but it can wait momentarily until the bleeding is under control. The immediate priority is to stop the bleeding.
Choice D rationale
Monitoring the pulse distal to the insertion site is important, but controlling bleeding takes precedence. Once the bleeding is controlled, the nurse can then monitor the pulse. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
The first voided specimen is discarded to ensure that the 24-hour urine collection starts with an empty bladder and accurately reflects the urine produced over the entire period.
Choice B rationale
Voiding every hour is not necessary and may not be practical for a 24-hour urine collection.
Choice C rationale
The final specimen should be included in the same container as the rest of the 24-hour urine collection.
Choice D rationale
Cleansing the perineum with a povidone-iodine solution is not required for a 24-hour urine collection.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
A digoxin level of 1.2 ng/mL is within the therapeutic range (0.8 to 2 ng/mL) for toddlers receiving digoxin therapy. This level does not require a revision of the plan of care.
Choice B rationale
An apical pulse of 100/min is within the normal range for toddlers. Digoxin therapy requires monitoring of the heart rate, but this pulse rate does not necessitate a change in the plan of care.
Choice C rationale
A potassium level of 4.0 mEq/L is within the normal range (3.4 to 4.7 mEq/L) for toddlers. This electrolyte level does not require a revision of the plan of care.
Choice D rationale
Vomiting is a potential sign of digoxin toxicity. A toddler who has vomited 2 times in the last hour may be experiencing digoxin toxicity, and the plan of care should be revised to address this issue. .
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