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 B

Explanation

A. The nurse should not make a judgment about the client’s benefit from reviewing their notes; the
client has the right to access their records.
B. Psychotherapy notes are protected and are not included in the general medical record. The nurse should inform the client of this policy.
C. Asking if the client is happy with treatment could be perceived as dismissive and irrelevant to the
client’s right to access their records.
D. The nurse should not question the client’s motivation but rather provide accurate information about the process for obtaining their records.

A. Place a towel roll under the client's neck. B. Align a trochanter wedge between the client's legs. C. Position a pillow under the client's knees. D. Apply an orthotic to the client's foot.

Correct Answer is D

Explanation

A. A towel roll under the neck is not effective for preventing contractures, which most commonly affect the arms and legs.
B. A trochanter wedge helps to maintain proper alignment of the hips but does not address contractures in the limbs.
C. A pillow under the knees can lead to contractures in the legs. It is more effective to keep the legs straight with proper positioning.
D. An orthotic to the foot can help prevent foot drop and other contractures in the lower extremities by maintaining the proper position.

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