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 incorrect, as sodium excess is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Sodium excess, or hypernatremia, is a condition where the blood sodium level is too high, which can result from excessive intake or loss of water. The symptoms of sodium excess may include thirst, dry mouth, confusion, seizures, or coma.
Choice B reason: This statement is incorrect, as overhydration is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Overhydration, or hypervolemia, is a condition where the body has too much fluid, which can result from excessive intake or retention of water. The symptoms of overhydration may include edema, weight gain, shortness of breath, or crackles in the lungs.
Choice C reason: This statement is correct, as dehydration is the most likely cause of the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Dehydration is a condition where the body loses more fluid than it takes in, which can result from vomiting, diarrhea, fever, or inadequate intake of water. The symptoms of dehydration may include dry skin, sunken eyes, decreased urine output, or lethargy.
Choice D reason: This statement is incorrect, as calcium excess is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Calcium excess, or hypercalcemia, is a condition where the blood calcium level is too high, which can result from hyperparathyroidism, malignancy, or excessive intake of vitamin D or calcium. The symptoms of calcium excess may include nausea, constipation, muscle weakness, or kidney stones.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as most infants are ready to start solid foods when they are 4 to 6 months old, depending on their individual growth and readiness. The nurse should explain to the parents that some signs of readiness include being able to hold the head up, sit with support, show interest in food, and move food from the spoon to the throat.
Choice B reason: This statement is incorrect, as 2 to 3 months is too early to introduce solid foods to infants, as their digestive system and swallowing skills are not mature enough to handle them. The nurse should advise the parents to avoid giving solid foods before 4 months of age, as it can increase the risk of choking, allergies, obesity, and iron deficiency.
Choice C reason: This statement is incorrect, as 1 year is too late to introduce solid foods to infants, as they need more nutrients and calories than breast milk or formula alone can provide. The nurse should inform the parents that delaying solid foods beyond 6 months of age can lead to growth faltering, micronutrient deficiencies, and feeding difficulties.
Choice D reason: This statement is incorrect, as 10 to 11 months is too late to introduce solid foods to infants, as they need more nutrients and calories than breast milk or formula alone can provide. The nurse should inform the parents that delaying solid foods beyond 6 months of age can lead to growth faltering, micronutrient deficiencies, and feeding difficulties.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.