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. This is the first step to control bleeding and prevent further blood loss.
B. Monitoring the distal pulse is important, but controlling bleeding takes precedence.
C. Vital signs can wait momentarily until the bleeding is under control.
D. Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the first step to control bleeding and prevent further blood loss.
B. Monitoring the distal pulse is important, but controlling bleeding takes precedence.
C. Vital signs can wait momentarily until the bleeding is under control.
D. Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority.
Correct Answer is D
Explanation
A. Offering a prize for not crying may inadvertently reinforce crying as an expectation.
B. This statement is not accurate because the medicine might not fix the problem or make the child feel better immediately.
C. Assuring the child that they will only feel a little stick is not honest because the injection might hurt more than a little stick, and lying to the child can damage the trust between the nurse and the child.
D. Allowing the child to choose the injection site allows the child to have some control and autonomy over the situation, which can reduce anxiety and fear.
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