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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bedside computer keyboards are frequently touched by healthcare providers, visitors, and sometimes the patient themselves. This constant contact can lead to the accumulation of bacteria and viruses, making it a common source of healthcare-associated infections.
B. While protective gowns can harbor microorganisms, they are typically single-use items and disposed of after each patient, minimizing the risk of infection transmission.
C. Unopened formula bottles are sterile and not a source of infection.
D. Disposable diapers are designed to be hygienic and are not a significant source of infection.
Correct Answer is B
Explanation
A. While Kegel exercises can be beneficial for bladder control, they are not typically part of conditioning therapy for enuresis.
B. This statement indicates that the conditioning therapy (often involving a bedwetting alarm) is working. The child is waking up and responding to the urge to urinate.
C. Reducing fluid intake is not a recommended approach for enuresis treatment. Adequate hydration is important for overall health and bladder function.
D. While bladder control is important, holding urine for extended periods is not the goal of enuresis treatment. The focus is on waking up and responding to the urge to urinate.
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