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 D

Explanation

A. Mild discomfort at the insertion site is expected following a cardiac catheterization. It should be monitored, but it is not a concern unless it worsens or is accompanied by other signs of complications.
B. Bounding pulses may indicate increased blood flow and may not necessarily be a concern. However, they should be monitored for any changes.
C. A heart rate of 90/min is within the normal range for many clients post-procedure and is not an immediate cause for concern.
D. A hematoma at the insertion site could indicate bleeding or a clot and may require urgent intervention to prevent further complications such as ischemia or hemorrhage.

A. Pulse rate 100/min B. 1+ proteinuria via urine dipstick C. Deep tendon reflexes 2+ D. Urine output 20 mL/hr

Correct Answer is C

Explanation

A. A pulse rate of 100/min is within the expected range and is not an indication for concern with magnesium sulfate administration.
B. Proteinuria of 1+ indicates mild protein in the urine, which is a sign of preeclampsia, not necessarily a therapeutic effect of magnesium sulfate.
C. Monitoring deep tendon reflexes for signs of magnesium sulfate toxicity (e.g., loss of reflexes) is essential.
D. Urine output of 20 mL/hr is below the expected output and may indicate toxicity or kidney issues, so it should be carefully monitored.

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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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