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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The nurse should not encourage flexion and extension of the neck, as this could cause further injury or damage to the spinal cord.
B. The nurse should reposition the client using a turning sheet to prevent skin breakdown and maintain alignment of the spine.
C. The nurse should assess the pin sites for infection at least once a day, not every other day.
D. The nurse should not tighten the screws on the halo device, as this could cause pressure ulcers or nerve damage. Only a provider can adjust the screws on the halo device.
Correct Answer is B
Explanation
A. Increased capillary refill time is not typically associated with hypoglycemia. It may indicate poor peripheral circulation.
B. Shakiness or tremors are common signs of hypoglycemia, as the body responds to low blood sugar levels.
C. Thirst is not typically associated with hypoglycemia. It may be a symptom of hyperglycemia, where blood sugar levels are high.
D. While decreased appetite can occur with hypoglycemia, it is not as specific a symptom as shakiness. It can also occur due to various other reasons.
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