The nurse is caring for a child who has undergone cardiac catheterization. During the recovery, the nurse notices that the dressing is saturated with bright red blood. The nurse's first action is to:
Apply direct pressure 1 inch above the puncture site
Notify the Cardiac Cath Lab that the child will be returning
Place a call to the Interventional Radiologist
Apply a bulky pressure dressing over the present dressing
The Correct Answer is A
A. Bright red blood indicates active arterial bleeding, most likely from the femoral artery used during the cardiac catheterization. The first priority is to stop the bleeding. Direct pressure should be applied just above the puncture site to help control the bleeding and prevent further blood loss.
B. While notifying the Cath Lab may be necessary later, intervention to stop the bleeding must come first to ensure patient safety.
C. Contacting the Interventional Radiologist may eventually be required, but it is not the first action. Immediate pressure to control bleeding is more urgent.
D. Applying a bulky dressing alone without direct pressure is inadequate in managing arterial bleeding and may delay life-saving intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The pressure dressing is usually removed within 24 hours, not left on for 7 days. Extended dressing use may increase the risk of skin irritation or infection.
B. Strict bed rest is typically recommended for a few hours after the procedure, not for three days. Most adolescents can resume light activity within 24 hours.
C. After a cardiac catheterization, tub baths should be avoided for 2–3 days to prevent infection at the insertion site, but showering is generally safe the next day, provided the site is protected and not scrubbed.
D. Returning to school is typically permitted within 1 to 2 days after the procedure, depending on the child’s condition and physician recommendations—Band-Aid removal is not a relevant factor in determining return to school.
Correct Answer is B
Explanation
A. Increased urine output is not typical in early congestive heart failure (CHF); in fact, decreased urine output can occur due to reduced kidney perfusion.
B. Tachypnea (rapid breathing) is an early and key sign of CHF in children. It occurs due to pulmonary congestion and decreased cardiac output, leading to poor oxygenation and compensatory increased respiratory rate.
C. Bradycardia is a late and often ominous sign of cardiac deterioration in children, not an early indicator.
D. Inability to sweat is not a recognized clinical indicator of CHF. On the contrary, diaphoresis (especially during feeding in infants) can be an early sign.
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