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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answers are choices B. Administer Benadryl, and D. Apply a cool compress.

Choice A rationale:

Placing an ace wrap on the bite is not recommended for a brown recluse spider bite. This action could potentially worsen the situation as it might trap venom in the area and increase the risk of necrosis.

Choice B rationale:

Administering Benadryl is a suitable action for alleviating pain and managing allergic reactions related to the bite. Benadryl (diphenhydramine) is an antihistamine that can help reduce itching and inflammation.

Choice C rationale:

Elevating the affected area might not provide significant pain relief for a brown recluse spider bite. Elevating is generally more effective for reducing swelling associated with injuries involving fluid accumulation, like sprains or strains.

Choice D rationale:

Applying a cool compress to the bite area can help alleviate pain and reduce inflammation. Cold therapy constricts blood vessels, which can reduce swelling and numb the area, providing relief.

A. Recommend salicylates instead of acetaminophen for minor discomforts. B. Encourage routine cholesterol screenings. C. Conduct routine blood pressure screenings. D. Refer children with sore throats for throat cultures.

Correct Answer is D

Explanation

The correct answer is Choice D: Refer children with sore throats for throat cultures.

Choice A rationale:

Recommending salicylates instead of acetaminophen for minor discomforts is not relevant to the prevention of rheumatic fever. Rheumatic fever is primarily associated with untreated streptococcal infections, particularly streptococcal pharyngitis (strep throat), which can lead to complications such as rheumatic fever if left untreated. The choice of pain relievers like salicylates or acetaminophen doesn't play a significant role in preventing rheumatic fever.

Choice B rationale:

Encouraging routine cholesterol screenings is not relevant to the prevention of rheumatic fever. Rheumatic fever is an immune-mediated inflammatory response to certain strains of Streptococcus bacteria, particularly Streptococcus pyogenes. Cholesterol screenings are more related to assessing cardiovascular risk and are not directly linked to preventing rheumatic fever.

Choice C rationale:

Conducting routine blood pressure screenings is not directly related to the prevention of rheumatic fever. Blood pressure screenings are important for identifying hypertension and other cardiovascular risk factors, but they do not have a direct impact on preventing rheumatic fever, which is primarily a complication of untreated streptococcal infections.

Choice D rationale:

Refer children with sore throats for throat cultures. This is the correct choice. Rheumatic fever often develops as a result of untreated streptococcal pharyngitis (strep throat). Throat cultures are crucial for diagnosing streptococcal infections and determining the appropriate course of treatment with antibiotics. By identifying and treating streptococcal infections promptly, the risk of developing rheumatic fever can be significantly reduced.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child has come into the emergency department after a confirmed bite from a brown recluse. Which action can the nurse take to alleviate pain?

Correct Answer is B

Explanation

Which action by the school nurse is important in the prevention of rheumatic fever?

Correct Answer is D

Explanation

The viral pathogen that frequently causes acute diarrhea in young children is:

The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined?

The nurse, caring for an infant whose cleft lip was repaired, should include which interventions in the infant's postoperative plan of care? (Select all that apply.).

What is a common side effect of corticosteroid therapy?

A nurse is planning care for a school-age child diagnosed with type 1 diabetes. Which insulin preparations are either rapid or short acting? (Select all that apply.).

Which type of croup is always considered a medical emergency?

The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.)