An 18-month-old child returned from the cardiac cath lab 1/2 hour ago. The child wakes up and begins crying. The nurse notices that the pressure dressing is becoming saturated with blood. The nurse's first action should be to:
Remove the dressing to identify where the bleeding is coming from
Let the parent hold the child to calm him
Put direct pressure on the dressing to stop the bleeding
Draw up the ordered morphine to calm the child
The Correct Answer is C
Choice A reason: This is not a good choice. Removing the dressing to identify where the bleeding is coming from can increase the risk of infection and further bleeding. The nurse should keep the dressing in place and apply direct pressure to control the bleeding.
Choice B reason: This is not a good choice. Letting the parent hold the child to calm him can worsen the bleeding by increasing the blood pressure and heart rate. The nurse should keep the child in a supine position and reassure him while applying direct pressure to the dressing.
Choice C reason: This is the correct choice. Putting direct pressure on the dressing to stop the bleeding is the first and most effective action to take in this situation. The nurse should use a sterile gauze pad or a gloved hand to apply firm and continuous pressure to the dressing until the bleeding stops or medical assistance arrives.
Choice D reason: This is not a good choice. Drawing up the ordered morphine to calm the child is not the priority action in this situation. The nurse should first stop the bleeding and then assess the child's pain level and administer the appropriate analgesic. Morphine can also cause respiratory depression and hypotension, which can complicate the child's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is false, as a sense of hopelessness and despair are not a normal part of adolescence, but signs of depression and suicidal ideation. The nurse should educate the adolescents and their parents about the warning signs of suicide and the importance of seeking professional help.
Choice B reason: This statement is false, as previous suicide attempts are a major risk factor for completed suicides. The nurse should assess the adolescents for any history of self-harm or suicide attempts and provide them with appropriate interventions and referrals.
Choice C reason: This statement is true, as LGBT adolescents are at a particularly high risk for suicide due to the stigma, discrimination, and bullying they may face from their peers, family, and society. The nurse should provide a safe and supportive environment for the LGBT adolescents and connect them with resources and support groups.
Choice D reason: This statement is false, as problem-solving skills are of great value to the suicidal adolescent. The nurse should teach the adolescents how to cope with stress, deal with conflicts, and seek help when needed. The nurse should also help the adolescents develop positive self-esteem and resilience.
Correct Answer is D
Explanation
Choice A reason: This is not a good choice. Septic shock is a type of distributive shock that occurs when an infection causes a systemic inflammatory response that leads to vasodilation, hypotension, and organ dysfunction. Septic shock is not the most common type of shock in children, although it can be a serious and life-threatening condition.
Choice B reason: This is not a good choice. Anaphylactic shock is a type of distributive shock that occurs when an allergic reaction causes a severe and rapid hypersensitivity response that leads to bronchoconstriction, angioedema, and hypotension. Anaphylactic shock is not the most common type of shock in children, although it can be a medical emergency that requires immediate treatment.
Choice C reason: This is not a good choice. Distributive shock is a broad category of shock that occurs when there is a loss of vascular tone and blood volume distribution that leads to hypoperfusion and tissue hypoxia. Distributive shock can be caused by various factors, such as sepsis, anaphylaxis, neurogenic injury, or adrenal insufficiency. Distributive shock is not the most common type of shock in children, although it can be a complex and challenging condition to manage.
Choice D reason: This is the correct choice. Hypovolemic shock is the most common type of shock in children. Hypovolemic shock occurs when there is a loss of blood or fluid volume that leads to decreased preload, cardiac output, and blood pressure. Hypovolemic shock can be caused by various factors, such as hemorrhage, dehydration, vomiting, diarrhea, or burns. Hypovolemic shock can be a life-threatening condition that requires prompt fluid resuscitation and correction of the underlying cause.
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