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 A

Explanation

A. Administering a cathartic suppository 30 minutes prior to scheduled defecation times can help stimulate bowel movements in clients with spinal cord injuries, aiding in bowel training.
B. Refined grains can lead to constipation, and increasing fiber intake is typically preferred over refined grains in a bowel training program.
C. A cold drink is not a standard or recommended method to stimulate bowel movements in clients with spinal cord injuries.
D. Fluid intake should generally be higher than 1,500 mL per day, as adequate hydration is important to prevent constipation and support healthy bowel function.

A. Measure gastric residual volumes every 4 hr. B. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication. C. Advance the rate of the feeding every 2 hr. D. Maintain the head of the bed at a 20" angle.

Correct Answer is A

Explanation

A. Measuring gastric residual volumes every 4 hours is important to assess the client’s tolerance to the feeding and prevent aspiration.
B. Flushing with saline should only be done as necessary for medication administration and not routinely unless specified by protocol.
C. The rate of feeding should be adjusted based on the client’s tolerance and not increased arbitrarily.
D. The head of the bed should be maintained at 30–45° to reduce the risk of aspiration.

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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?

Nursing Test Bank

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