A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

Apply pressure just above the insertion site.

Monitor the pulse distal to the insertion site.

Obtain vital signs.

Reinforce the dressing.

Answer and Explanation

The Correct Answer is A

A.   This is the first and most critical action to take. If the dressing is saturated with blood, it indicates that there may be active bleeding at the catheter insertion site. Applying direct pressure just above the insertion site helps control bleeding by promoting clot formation and reducing blood flow to the area.
B.   Monitoring the pulse distal to the insertion site is important for assessing blood flow and identifying potential complications such as arterial occlusion or hematoma formation. However, it is not the first action to take when there is active bleeding. While this assessment is important, controlling the bleeding takes precedence.

C.   Obtaining vital signs is important for assessing the child’s overall condition and identifying signs of potential hemodynamic instability. However, it is not the first step when there is immediate, active bleeding. Addressing the bleeding directly is more urgent to prevent further complications.
D.   Reinforcing the dressing might be necessary if the bleeding has been controlled. However, if the dressing is already saturated, simply reinforcing it without addressing the underlying bleeding issue may not be effective and could delay necessary intervention.

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Correct Answer is B

Explanation

A. Lotions, powders, or ointments should be avoided under the harness as they can irritate the skin.
B. This helps protect the skin and keeps the harness clean.
C. Only a healthcare provider should adjust the harness straps. Parents should not attempt to do this.
D. Massage can irritate the skin and should be avoided.

A. Ask the child's parent to leave the room during the procedure. B. Explain the procedure in detail to the child 3 hr prior to the procedure. C. Perform the procedure in the unit's playroom. D. Apply a topical anesthetic cream 1 hr prior to the procedure.

Correct Answer is D

Explanation

A. A child might feel more anxious without a parent present. The parent's presence can provide comfort and support.
B. Overly detailed explanations might increase anxiety. Providing simple, age-appropriate information just before the procedure is more effective.

C. The playroom is associated with fun activities. Performing a medical procedure in this environment can create negative associations.
D. Applying a topical anesthetic cream before the procedure can significantly reduce pain and discomfort during venipuncture, providing atraumatic care.

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A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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