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 C
Explanation
The correct answer is Choice C.
Choice A rationale
Having their cell phone visible and diverting the eyes to check messages is not an effective nonverbal technique for enhancing the importance of education. It can be distracting and may convey a lack of interest or attention to the client.
Choice B rationale
Crossing arms over the chest and avoiding eye contact can be perceived as defensive or disinterested body language. It does not enhance the importance of education and may create a barrier to effective communication.
Choice C rationale
Smiling, nodding, and touching the client’s hand are positive nonverbal techniques that can enhance the importance of education. These actions convey warmth, empathy, and attentiveness, making the client feel valued and understood.
Choice D rationale
Leaning gently over the back of a chair with legs crossed can be perceived as casual or relaxed body language. It does not convey the importance of the education being provided.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Continuous swallowing can be an indication of hemorrhage following a tonsillectomy and adenoidectomy. This is because the child may be swallowing blood that is coming from the surgical site.
Choice B rationale
Blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
Choice C rationale
A heart rate of 54/min is lower than the normal range for a 5-year-old child and may indicate bradycardia, but it is not a specific sign of hemorrhage.
Choice D rationale
Flushing of the face is not a specific sign of hemorrhage. It may indicate other conditions but is not typically associated with bleeding following a tonsillectomy and adenoidectomy.
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