A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?
Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site.
Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.
The Correct Answer is B
A. Applying intermittent pressure may not effectively stop bleeding from a cardiac catheterization site, as continuous pressure is typically more effective in controlling post-procedural bleeding.
B. Applying continuous pressure 2.5 cm above the percutaneous site is the appropriate action to stop bleeding from the catheterization site.
C. Applying pressure below the site may not effectively control bleeding and could compromise the site.
D. Continuous pressure should be applied above the percutaneous site, not below, to control bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The shoulders are not the most reliable location for assessing cyanosis, especially in clients with dark skin.
B. The area of trauma may show changes in color, but it is not an ideal location for assessing cyanosis.
C. The palms of the hands are a better location to assess for cyanosis, as changes in oxygenation are more visible here, even in dark-skinned individuals.
D. The sacrum is generally not the most reliable location for detecting cyanosis in dark-skinned clients.
Correct Answer is B
Explanation
A. Lying down in a quiet room may not be the best approach as it may isolate the client further. A more active approach is needed to engage with the client.
B. Asking the client directly what they are hearing helps assess the content of the hallucinations and can
provide insight into the client’s experience.
C. Avoiding eye contact may increase anxiety or suggest a lack of concern. Maintaining appropriate eye contact is generally supportive.
D. Referring to hallucinations as real can reinforce delusions and is not therapeutic.
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