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 C
Explanation
A. Increased urine output – Decreased urine output is expected due to poor renal perfusion.
B. Hypertension – Heart failure in children typically causes low blood pressure due to poor cardiac output.
C. Diaphoresis – Increased sympathetic nervous system activity in pediatric heart failure leads to excessive sweating, especially during feeding.
D. Bradycardia – Tachycardia, not bradycardia, is a key sign of heart failure as the heart tries to compensate for poor circulation.
Correct Answer is D
Explanation
A. A 2-year-old toddler – Not the standard age for MCV4; however, high-risk infants (e.g., asplenic children) may receive a different meningococcal vaccine.
B. A 4-month-old infant – Too young for MCV4; infants may receive the MenB vaccine in special cases.
C. A 4-year-old child – Not part of the routine meningococcal vaccine schedule.
D. An 11-year-old school-age child – The MCV4 vaccine is recommended at ages 11-12, with a booster at age 16 to protect against bacterial meningitis.
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