The nurse is caring for a school-age child who has had a cardiac catherization, and upon assessment of the leg finds the bandage and the bed soaked with blood. Which is the priority nursing action?
Notify the physician.
Place the child in Trendelenburg position.
Apply a new bandage.
Apply direct pressure above catherization site.
The Correct Answer is D
A. While the physician should be informed, the priority action is to stop the bleeding first before seeking further medical advice.
B. The Trendelenburg position (feet elevated) does not directly control bleeding and is not recommended for bleeding at a catheterization site.
C. Simply placing a new bandage does not provide adequate pressure to stop active bleeding.
D. Applying direct pressure above the catheterization site is the priority to stop bleeding and prevent complications like hypovolemic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The influenza vaccine is not routinely given before 6 months of age.
B. DTaP is not contraindicated and should be given on schedule.
C. Withholding vaccines unnecessarily delays protection.
D. The presence of a mild illness or exposure to illness (such as flu) is not a contraindication to routine vaccinations. The infant should receive all scheduled vaccines.
Correct Answer is D
Explanation
A. Antibiotic use does not contraindicate MMR unless the child has a severe illness.
B. Mild illnesses with low-grade fevers are not contraindications.
C. A past mild fever from previous vaccines is not a contraindication.
D. MMR is a live vaccine and is contraindicated in children with congenital immunodeficiencies (e.g., SCID) because it can cause severe infections.
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