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.   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.

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Correct Answer is C

Explanation

A. Tying restraints to the side rails poses a risk of injury to the child and is not a recommended practice.
B. Renewing the prescription for restraints every 48 hours is important, but it does not directly address the proper application of restraints.
C. Securing restraints with a quick-release knot allows for quick removal in case of emergency and is the correct method for applying restraints.
D. Assessing the child every 4 hours while in restraints is important, but it does not address the proper application of restraints.

A. Resistant to routines B. Frequent negative responses C. Less emotionally labile D. Increased dependency

Correct Answer is B

Explanation

A. Toddlers thrive on routines and consistency, which provide them with security and predictability.
B. Toddlers are in a stage of development where they assert their independence and autonomy by saying "no" or "mine" to almost everything. This is a normal and healthy behavior that reflects their growing sense of self and identity. The nurse should explain to the guardian that this behavior is not meant to be defiant or disrespectful, but rather a way of exploring their environment and expressing their preferences.
C. Toddlers are typically emotionally labile, meaning they can experience rapid changes in mood and emotions.
D. Toddlers may display increased independence rather than increased dependency as they strive to assert their autonomy.

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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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