A nurse is caring for a school-age child who is 2 hr postoperative following 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 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.
Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
The Correct Answer is D
This is because bleeding after a cardiac catheterization is a possible complication that can occur when a catheter is inserted into an artery in the groin or arm to examine the heart. Bleeding can drip or spurt from the puncture site, or form a lump under the skin called a hematoma. Applying continuous pressure above the site can help stop the bleeding and prevent hematoma formation.
Choice A is wrong because applying intermittent pressure 2.5 cm (1 in) above the percutaneous skin site may not be enough to control the bleeding and may increase the risk of hematoma.
Choice B is wrong because applying intermittent pressure 2.5 cm (1 in) below the percutaneous skin site may not be effective and may cause more damage to the artery.
Choice C is wrong because applying continuous pressure 2.5 cm (1 in) below the percutaneous skin site may also be ineffective and harmful to the artery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.
Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.
The nurse should provide a structured and consistent daily routine for the client.
Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.
The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.
Correct Answer is A
Explanation
This is because boundaries can help the client and family to respect each other’s roles, needs, and preferences, and to avoid role confusion, resentment, or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
Choice B is wrong because minimizing open discussion regarding the changes can lead to misunderstanding, frustration, or isolation. The client and family should communicate openly and honestly about their feelings, expectations, and challenges, and seek support when needed.
Choice C is wrong because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
Choice D is wrong because decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.
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