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 B

Explanation

A. Abstinence is the only guaranteed way to prevent STIs.
B. Early detection and treatment of STIs can prevent serious health problems, including infertility, pelvic inflammatory disease, and chronic pain.
C. While having one faithful partner who is also only with you reduces the risk, it doesn't eliminate it completely. New partners can introduce STIs.
D. Adolescents are at increased risk for STIs due to various factors, including hormonal changes, experimentation, and lack of consistent condom use.

A. Apply cold compresses to the affected joints. B. Place the client on strict bed rest. C. Give oral hydroxyurea. D. Instruct the parent to ensure the pneumococcal vaccine is current. E. Administer folic acid as prescribed. F. Administer meperidine IV for pain. G. Monitor oxygen saturation continuously. H. Restrict oral intake.

Correct Answer is ["B","D","E","G","H"]

Explanation

A. Cold compresses can worsen pain and vasoconstriction, which is counterproductive in a vaso- occlusive crisis. Warm compresses are typically recommended.
B. Reducing physical activity helps to decrease oxygen demand and minimize pain during a vaso- occlusive crisis.
C. Hydroxyurea is a medication used to prevent vaso-occlusive crises, but it is not a treatment for an acute crisis.
D. Patients with sickle cell disease are at increased risk for infections, and the pneumococcal vaccine is crucial for prevention.
E. Folic acid supplementation is recommended for individuals with sickle cell disease to help prevent anemia.
F. Meperidine is no longer recommended for pain management due to its potential for toxic metabolites. Other pain medications, such as opioids like morphine or hydromorphone, would be more appropriate.
G. Close monitoring of oxygen saturation is essential to detect early signs of respiratory compromise.
H. Nausea and vomiting are common during a vaso-occlusive crisis, and restricting oral intake can help prevent dehydration and electrolyte imbalances.

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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

Naxlex Comprehensive Predictor Exams

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