The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the most appropriate initial nursing action?
Place the child in the Trendelenburg position.
Apply a new bandage with more pressure.
Notify the physician.
Apply direct pressure above the catheterization site.
The Correct Answer is D
Answer is: d. Apply direct pressure above the catheterization site.
Explanation: The first action should be to apply direct pressure above the catheterization site to help control the bleeding and minimize blood loss. This will also give the nurse time to prepare additional interventions or supplies if necessary.
Choice a. is wrong because placing the child in the Trendelenburg position is not an appropriate initial nursing action in this scenario. This position can increase intracranial pressure and is typically used for patients experiencing shock or hypotension.
Choice b. is wrong because applying a new bandage with more pressure might be a subsequent action, but the priority is to apply direct pressure to slow down the bleeding.
Choice c. is wrong because notifying the physician is important, but the nurse should first take immediate action to control the bleeding and minimize potential harm to the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The cuff bladder covers 50% to 66% of the length of the upper arm.
Choice A rationale:
Selecting a blood pressure cuff with a bladder that covers 50% to 66% of the length of the upper arm is the appropriate criterion for determining the cuff size for a 2-year-old boy. This range ensures accurate blood pressure measurement by ensuring a proper fit on the arm. If the cuff bladder is too small or too large, it can result in inaccurate readings.
Choice B rationale:
The label "toddler" on the cuff might be helpful in identifying the intended age group, but it doesn't provide precise measurements for cuff sizing. Relying solely on a label might not account for variations in arm sizes within the toddler age group.
Choice C rationale:
The cuff bladder width being 40% of the circumference of the upper arm might not be as accurate as the length-based criterion. A cuff that fits the arm's length is more critical in ensuring proper inflation and accurate blood pressure measurement.
Choice D rationale:
The cuff bladder length covering 80% to 100% of the circumference of the upper arm might result in an excessively large cuff for a 2-year-old, which can lead to inaccurate readings. Length-based sizing is more appropriate for accuracy in this scenario.
Correct Answer is ["C","D"]
Explanation
The correct answers are choices C. Novolin R, and D. NovoLog.
Choice A rationale:
Novolin N is an intermediate-acting insulin, not rapid or short acting. It has a slower onset and longer duration of action, making it unsuitable for rapid blood sugar control.
Choice B rationale:
Lantus is a long-acting insulin that provides basal insulin coverage and has a relatively steady effect over 24 hours. It is not rapid or short acting and is used to provide a baseline level of insulin, not for immediate blood sugar control.
Choice C rationale:
Novolin R, also known as regular insulin, is a short-acting insulin with an onset of about 30 minutes and a peak effect around 2 to 3 hours. It is often used to cover mealtime blood sugar elevations and is suitable for short-term blood sugar control.
Choice D rationale:
NovoLog is a rapid-acting insulin analog with an onset of about 15 minutes and a peak effect within 1 to 2 hours. It is designed to mimic the body's rapid insulin release after meals, making it effective for controlling postprandial blood sugar levels.
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