A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?

Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site.

Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.

Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.

Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.

Answer and Explanation

The Correct Answer is B

A.   Applying intermittent pressure may not effectively stop bleeding from a cardiac catheterization site, as continuous pressure is typically more effective in controlling post-procedural bleeding.
B.   Applying continuous pressure 2.5 cm above the percutaneous site is the appropriate action to stop bleeding from the catheterization site.
C.   Applying pressure below the site may not effectively control bleeding and could compromise the site.
D.   Continuous pressure should be applied above the percutaneous site, not below, to control bleeding.

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Correct Answer is C

Explanation

A. Infusing vancomycin at a faster rate could increase the risk of infusion-related reactions such as "red man syndrome" and is not recommended.
B. While a slight adjustment may be possible, 30 minutes is a short timeframe, and altering the time significantly could affect the therapeutic efficacy or safety of the drug.
C. The nurse typically has a 2-hour window to administer medications like vancomycin, but this should be done according to facility policy and the specific medication schedule.
D. Adjusting the time and schedule to the client's convenience may not ensure that the medication is administered effectively and within the proper timeframe.

A. Drink 1.5 L of fluids each day. B. Increase exercise activity. C. Take mineral oil at bedtime. D. Decrease insoluble fiber intake.

Correct Answer is B

Explanation

A. While adequate fluid intake is important, 1.5 L per day might not be sufficient for a client with chronic pain and opioid use. The client should aim for a higher intake, as recommended by healthcare providers.
B. Increasing physical activity helps promote bowel motility, reducing the risk of constipation. Regular exercise can help counteract opioid-induced constipation.
C. Mineral oil should not be recommended due to its risk of aspiration and interference with vitamin absorption.
D. Insoluble fiber is necessary to help with bowel movements and should be increased, not decreased, to help prevent constipation.

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A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?

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