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.
Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
Apply direct pressure to the puncture site.
Elevate the affected extremity above the level of the heart.
Leave the dressing undisturbed and notify the physician immediately.
The Correct Answer is B
The correct answer is choice B. Apply direct pressure to the puncture site.
Choice A rationale:
Applying intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site is not the best approach. This method may not effectively control the bleeding and could potentially dislodge the introducer sheath.
Choice B rationale:
Applying direct pressure to the puncture site is the most effective way to control bleeding. Direct pressure helps to promote clot formation and reduce blood flow to the area, which is crucial in managing postoperative bleeding.
Choice C rationale:
Elevating the affected extremity above the level of the heart is not appropriate in this situation. While elevation can reduce swelling, it does not address the immediate need to control active bleeding.
Choice D rationale:
Leaving the dressing undisturbed and notifying the physician immediately is not advisable. Immediate action to control the bleeding is necessary before notifying the physician. Delaying intervention could lead to significant blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states.
Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.
Choice B is wrong because antitoxin is not used to treat Lyme disease.
Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.
Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the
bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.
Choice D is wrong because skin necrosis is not a common complication of Lyme disease.
Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.
Correct Answer is D
Explanation
D) Scrambled eggs and toast with milk.
For a client who follows kosher dietary traditions, it's essential to adhere to the rules and restrictions that pertain to kosher food preparation and consumption. Among the given options, the only one that aligns with kosher dietary guidelines is scrambled eggs and toast with milk.
The other options (A, B, and C) contain non-kosher ingredients, such as ham, shrimp, and bacon, which are not considered kosher. Additionally, mixing meat and dairy products is generally not allowed in kosher dietary practices. So, options A, B, and C would not be appropriate for someone following kosher dietary traditions.
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