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.
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Related Questions
Correct Answer is ["A","C","D","E","G"]
Explanation
A. Continuous monitoring of oxygen saturation is crucial in a vaso-occlusive crisis to detect any signs of hypoxia early, which could exacerbate the crisis and lead to more severe complications. This is important for assessing respiratory status, especially in patients with sickle cell disease who may be at risk for acute chest syndrome.
B. Oral intake should not be restricted during a vaso-occlusive crisis as hydration is important for maintaining adequate blood flow and preventing dehydration.
C. Hydroxyurea is used to reduce the frequency of painful crises in patients with sickle cell disease. It works by increasing the production of fetal hemoglobin, which can help prevent sickle cell crises.
D. Meperidine (Demerol) is an opioid analgesic commonly used to manage severe pain associated with sickle cell crises.
E. Vaccination is important in preventing infections, which can trigger or worsen a vaso-occlusive crisis in individuals with sickle cell disease. Ensuring the pneumococcal vaccine is current helps protect the adolescent from potential infections.
F. Placing the client on strict bed rest can increase the risk of thrombosis and impair circulation.
G. Folic acid supplementation is often recommended for patients with sickle cell disease to support red blood cell production and prevent folate deficiency, which can worsen anemia.
H. Cold compresses are not recommended as they can cause vasoconstriction, worsening the pain and sickling in vaso-occlusive crises. Warm compresses are generally preferred.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Options 1:
A. Keeping the child NPO is crucial to prevent further ingestion or aspiration of the battery, which could lead to serious complications.
B. Teaching the child's parents the importance of inspecting the child's play area is important for future prevention but is not the immediate priority in this acute situation.
C. Obtaining an informed consent is not the priority in this scenario. It should be done after keeping the child NPO.
Options 2:
A. Encouraging parents to inspect toys for easily removable parts is important for prevention but is not the immediate priority when dealing with a child who has already ingested a foreign object.
B. Preparing the child for flexible endoscopy is the second action to visualize and safely remove the battery from the esophagus.
C. Waiting for return of the gag reflex without taking immediate action could delay potentially life-saving interventions.
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