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 B
Explanation
A. Blood products should always be administered through a filtered IV tubing to remove any potential contaminants.
B. Blood products should typically be infused within 4 hours to reduce the risk of bacterial contamination.
C. Dextrose 5% in water can cause hemolysis of red blood cells. Packed RBCs should be infused with normal saline (0.9% sodium chloride).
D. Blood products should be stored at a specific temperature, typically refrigerated, to maintain their viability. Bringing them to room temperature for an extended period can compromise their quality.
Correct Answer is D
Explanation
A. Toddlers are typically moving towards independence, not increased dependency. This is a stage of exploration and asserting their autonomy.
B. Toddlers are known for their intense emotions and rapid mood swings. This is a normal part of their development.
C. While toddlers can be unpredictable, they often thrive on routines. However, they also enjoy exploring new things, which can sometimes lead to resistance to established routines.
D. The "terrible twos" is a common phrase for a reason. Toddlers often assert their independence through negative responses, such as saying "no" or throwing tantrums.
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