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
Providing a doll for the 3-year-old child to imitate parental behaviors helps the child understand and adjust to the new role of being an older sibling. It allows the child to practice nurturing behaviors and can reduce feelings of jealousy or displacement by involving them in the care of the newborn.
Choice B rationale
Preparing the child for a change in all of their routines can be overwhelming and may cause unnecessary stress. It is more effective to maintain as much consistency as possible in the child’s routine while gradually introducing changes related to the new sibling.
Choice C rationale
Telling the child that they will now have a new playmate may create unrealistic expectations. A newborn is not immediately capable of playing, and this statement may lead to disappointment and frustration for the 3-year-old.
Choice D rationale
Waiting for the newborn to come home before moving the 3-year-old from the crib to a bed can create a sense of displacement and jealousy. It is better to make this transition well before the newborn’s arrival to allow the older child to adjust to the change independently of the new sibling.
Correct Answer is D
Explanation
The correct answer is D. Varicella.
Choice A rationale
Rotavirus vaccination is typically administered in infancy, not at 5 years of age. The rotavirus vaccine is given to infants to protect against rotavirus infections, which can cause severe diarrhea and dehydration in young children. By the age of 5, children have usually completed the rotavirus vaccination series.
Choice B rationale
Hepatitis B vaccination is also typically completed in infancy. The hepatitis B vaccine is given to infants to protect against hepatitis B virus infection, which can cause chronic liver disease and liver cancer. By the age of 5, children who are up-to-date with their immunizations have usually completed the hepatitis B vaccination series.
Choice C rationale
Haemophilus influenzae type b (Hib) vaccination is typically completed by 15 months of age. The Hib vaccine protects against infections caused by Haemophilus influenzae type b, such as meningitis, pneumonia, and epiglottitis. By the age of 5, children who are up-to-date with their immunizations have usually completed the Hib vaccination series.
Choice D rationale
The second dose of the varicella vaccine is usually given at 4-6 years of age. The varicella vaccine protects against chickenpox, a highly contagious viral infection that causes an itchy
rash and fever. Administering the second dose of the varicella vaccine at this age helps ensure that the child has adequate immunity against chickenpox.
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