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 D
Explanation
The correct answer is Choice D.
Choice A rationale
Increased capillary refill time is not typically associated with hypoglycemia. It may indicate poor peripheral circulation but is not a common sign of low blood sugar levels.
Choice B rationale
Decreased appetite is not typically associated with hypoglycemia. Hypoglycemia usually causes symptoms such as shakiness, sweating, and confusion.
Choice C rationale
Thirst is not typically associated with hypoglycemia. It is more commonly a symptom of hyperglycemia (high blood sugar levels)9.
Choice D rationale
Shakiness or tremors are common signs of hypoglycemia. When blood sugar levels drop, the body responds by releasing adrenaline, which can cause shakiness.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed to assess pain in children who are unable to communicate their pain verbally, including those who are cognitively impaired. It evaluates five categories: facial expression, leg movement, activity, cry, and consolability, each scored from 0 to 2, with a total score ranging from 0 to 1012.
Choice B rationale
The FACES pain scale is a self-report tool that uses facial expressions to help children aged 3 and older communicate their pain level. It is not suitable for toddlers who are cognitively impaired and unable to self-report.
Choice C rationale
The Visual Analog Scale (VAS) is a unidimensional measure of pain intensity, typically used in older children and adults who can understand and mark their pain level on a continuum. It is not appropriate for toddlers who are cognitively impaired.
Choice D rationale
The CRIES scale is used to assess pain in neonates and infants, particularly postoperatively. It evaluates crying, oxygen requirement, increased vital signs, facial expression, and sleeplessness. It is not designed for toddlers.
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