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 C
Explanation
Banana slices are soft, easy to chew, and can be picked up by the toddler’s fingers, which promotes independence in eating. According to the CDC, foods that toddlers should avoid include:
- Added sugars and no-calorie sweeteners, such as sugar-sweetened and diet drinks
- High-salt foods, such as canned foods, processed meats, frozen dinners, fast food, and junk food
- Unpasteurized juice, milk, yogurt, or cheese
- Foods that may cause choking, such as hard or crunchy foods, sticky foods, stringy cheese, and foods that are not cut up into small pieces
Choice A is wrong because popcorn is a choking hazard for toddlers.
It is hard, crunchy, and can get stuck in the airway. The NHS advises not to give whole nuts and peanuts to children under 5 years old.
Choice B is wrong because grapes are also a choking hazard for toddlers.
They are round, slippery, and can block the airway. The NHS recommends cutting grapes into quarters before giving them to young children.
Choice D is wrong because hot dogs are high in salt and can cause choking if not cut up into small pieces. The Extension warns against giving hot dogs to young toddlers.
Correct Answer is B
Explanation
Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications. Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.
Choice A is wrong because decreasing insoluble fiber intake can worsen constipation. Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.
Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.
Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.
Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.
Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.
Laxatives should be used only as a last resort and under the guidance of a health care provider.
Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.
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