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. Applying pressure just above the insertion site helps to control bleeding by compressing the vessel and promoting hemostasis.
B. Monitoring the pulse distal to the insertion site is important but should occur after controlling the bleeding.
C. Obtaining vital signs is important but does not address the immediate need to control bleeding.
D. Reinforcing the dressing may be necessary after controlling the bleeding but is not the first action to take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Encouraging flexion and extension of the neck is contraindicated in a client with a halo vest to prevent further injury to the cervical spine.
B. Repositioning the client using a turning sheet helps to maintain proper alignment and prevent complications such as pressure ulcers.
C. Assessing the pin sites for infection should be done daily, not once every other day, to monitor for signs of infection.
D. Tightening the screws on the halo device should be done as prescribed by the healthcare provider and typically does not occur every 48 hours.
Correct Answer is A
Explanation
A. Daily weight monitoring is essential in managing nephrotic syndrome to assess for fluid retention and response to treatment.
B. Positioning the child supine at bedtime is not specific to the management of nephrotic syndrome.
C. Calorie intake may need to be increased rather than limited in nephrotic syndrome to compensate for protein loss and meet increased energy needs.
D. Fluid intake may need to be restricted rather than increased, depending on the child's fluid status and response to treatment.
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