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 step to control bleeding and prevent further blood loss.
B. Monitoring the distal pulse is important, but controlling bleeding takes precedence.
C. Vital signs can wait momentarily until the bleeding is under control.
D. Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority.
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Related Questions
Correct Answer is D
Explanation
A. Mixing the medication with formula may not be appropriate as the infant has vomited, and re-administering the medication immediately may result in overdosing.
B. Giving an antiemetic is not indicated unless ordered by the healthcare provider. It is important to follow specific orders in this situation.
C. Increasing fluid intake may not be advisable immediately after vomiting, especially in the context of heart failure. The infant may require evaluation for fluid status before increasing intake.
D. Administering the next dose as prescribed is the appropriate action unless contraindicated by specific circumstances or healthcare provider orders.
Correct Answer is D
Explanation
Rationale:
A. The child's throat pain is expected post-tonsillectomy and can be managed using analgesics or an ice collar. However, this is not a priority finding compared to frequent swallowing which may indicate bleeding which is a life-threatening complication of tonsillectomy.
B. Refusing clear liquids may indicate discomfort but is not as urgent as a potential increase in throat pain.
C. Crying often may be a response to discomfort but does not necessarily indicate a complication requiring immediate intervention.
D. This assessment finding indicates that the child might have bleeding in the throat, which is a life-threatening complication of tonsillectomy. The nurse should
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