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.
The Correct Answer is A
A. Applying pressure just above the insertion site helps to control bleeding by compressing the vessel and promoting hemostasis.
B. Monitoring the pulse distal to the insertion site is important but should occur after controlling the bleeding.
C. Obtaining vital signs is important but does not address the immediate need to control bleeding.
D. Reinforcing the dressing may be necessary after controlling the bleeding but is not the first action to take.
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Related Questions
Correct Answer is D
Explanation
A. Requesting assistance from the anesthesiologist may not directly address the guardian's misunderstanding about the procedure and may not be necessary unless there are specific anesthesia-related concerns.
B. While this option suggests a proactive approach by the nurse, it may not be appropriate unless the nurse is sufficiently knowledgeable about the specifics of the cardiac catheterization and has been delegated this task by the healthcare team. Typically, the primary responsibility lies with the healthcare provider performing the procedure.
C. Witnessing the adolescent's signature on the informed consent form is an important step in the consent process but does not directly address the guardian's misunderstanding about the procedure.
D. This action is appropriate because the provider has the knowledge and responsibility to explain why the cardiac catheterization is necessary, the benefits it offers, and any risks associated with the procedure. It ensures that the guardian receives accurate and detailed information directly from the expert who will be performing the procedure, facilitating an informed decision.
Correct Answer is B
Explanation
A. Increased capillary refill is not typically associated with hypoglycemia but may indicate poor peripheral circulation.
B. Shakiness is a common manifestation of hypoglycemia due to the release of epinephrine in response to low blood sugar levels.
C. Thirst is more commonly associated with hyperglycemia (high blood sugar levels) rather than hypoglycemia.
D. Decreased appetite may occur in hypoglycemia, but it is not as specific a symptom as shakiness.
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