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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. The child needs opportunities to play with peers.
Choice A rationale:
While it's important for children with congenital heart disease to understand their limitations, it's not the primary concern in this scenario. Allowing the child to interact and play with peers is essential for their social, emotional, and psychological development.
Choice B rationale:
While parents play a crucial role in a child's care, completely isolating the child from peers is not ideal. Overprotectiveness can lead to social isolation and hinder the child's ability to develop important social skills.
Choice C rationale:
Children with congenital heart disease should be encouraged to engage in age-appropriate physical activities and play with peers. Of course, the level of activity should be discussed with the child's healthcare provider, but limiting the child's interactions could have negative consequences on their overall development and emotional well-being.
Choice D rationale:
While supervision is important for any child's safety, constant parental supervision to avoid overexertion might not be necessary or feasible. Educating the child about their limitations and providing opportunities for play while monitoring their comfort level is a more balanced approach.
Correct Answer is D
Explanation
The correct answer is choice E. Board games.
Choice A rationale:
Computer games might not be the best choice for a child with osteomyelitis. These games involve prolonged screen time and limited physical movement, which could potentially hinder the child's recovery.
Choice B rationale:
Paper and paints involve a level of physical activity that might not be suitable for a child with osteomyelitis. The child's movement might be restricted due to the condition, and activities that require fine motor skills might not be comfortable for them.
Choice C rationale:
Jack-in-the-box involves sudden surprises and might startle the child, which could be detrimental to their recovery. Children with osteomyelitis might be dealing with pain and discomfort, so it's important to avoid activities that could cause unnecessary distress.
Choice D rationale:
Stuffed animals might be a comforting option for the child. However, the child might also experience pain or discomfort when handling stuffed animals due to their condition. It's better to choose activities that don't involve physical contact that could potentially exacerbate the child's symptoms.
Choice E rationale:
Board games are a suitable choice for a child with osteomyelitis. They provide mental stimulation and entertainment without requiring excessive physical activity. Board games also promote social interaction if played with others, which is important for the child's emotional well-being during their hospital stay.

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