A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

Apply pressure just above the insertion site.

Monitor the pulse distal to the insertion site.

Obtain vital signs.

Reinforce the dressing.

Answer and Explanation

The Correct Answer is A

A.   This is the first and most critical action to take. If the dressing is saturated with blood, it indicates that there may be active bleeding at the catheter insertion site. Applying direct pressure just above the insertion site helps control bleeding by promoting clot formation and reducing blood flow to the area.
B.   Monitoring the pulse distal to the insertion site is important for assessing blood flow and identifying potential complications such as arterial occlusion or hematoma formation. However, it is not the first action to take when there is active bleeding. While this assessment is important, controlling the bleeding takes precedence.

C.   Obtaining vital signs is important for assessing the child’s overall condition and identifying signs of potential hemodynamic instability. However, it is not the first step when there is immediate, active bleeding. Addressing the bleeding directly is more urgent to prevent further complications.
D.   Reinforcing the dressing might be necessary if the bleeding has been controlled. However, if the dressing is already saturated, simply reinforcing it without addressing the underlying bleeding issue may not be effective and could delay necessary intervention.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Keeping the child’s nails trimmed and filed helps prevent excessive scratching that can lead to skin infections and worsening of dermatitis. It reduces the risk of injury to the skin and minimizes the potential for secondary infections from scratching.
B. This is a key recommendation for managing atopic dermatitis. Emollients (moisturizers) should be applied immediately after bathing to help lock in moisture and prevent the skin from becoming dry, which can exacerbate the condition. Moisturizing regularly helps to soothe the skin and reduce itching.
C. Applying gloves or mittens can be helpful in preventing the child from scratching and irritating the skin. This is especially useful at night to minimize scratching while the child is asleep.
D. Using a mild, fragrance-free detergent is important to prevent irritation of the skin. Harsh chemicals and fragrances in regular detergents can exacerbate atopic dermatitis and irritate sensitive skin.
E. It is realistic to inform the guardian that atopic dermatitis is a chronic condition with potential flare- ups. Understanding that flare-ups are a normal part of the condition can help the guardian manage expectations and better cope with the condition over time.
F. Atopic dermatitis is not contagious. It is an allergic condition related to immune system dysfunction and genetic factors, not an infectious disease. Therefore, it cannot be spread to others.
G. While pimecrolimus cream is an effective treatment for atopic dermatitis, it should be applied according to the provider's instructions, which generally involve applying a thin layer rather than a thick layer. Overapplication can lead to potential side effects or diminished effectiveness.

A. Engages in parallel play B. Builds a tower of 3 blocks C. Walks with assistance D. Speaks at least 10 words

Correct Answer is C

Explanation

A. This is typical behavior for an 18-month-old toddler. They often play alongside others without interacting directly.
B. This is a normal developmental milestone for an 18-month-old child.
C. An 18-month-old child should be able to walk independently. Difficulty walking with assistance could indicate a potential developmental delay.
D. While vocabulary varies, most 18-month-olds can say a few words. This is within the normal range.

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A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

Nursing Test Bank

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Explanation

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