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.
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Related Questions
Correct Answer is B
Explanation
A. While urine output is important, it is not the most direct indicator of the success of a paracentesis.
B. Comparing the client's weight before and after the procedure helps to evaluate the effectiveness by showing a reduction in fluid buildup.
C. Leakage at the site could indicate a complication, but it is not the primary measure of the procedure’s
effectiveness.
D. Serum albumin levels may be monitored but are not the first indicator of success after a paracentesis.
Correct Answer is B
Explanation
A. The client's behavior should be assessed more frequently (e.g., every 15-30 minutes) during seclusion to ensure their safety.
B. Documenting the client's behavior prior to seclusion helps provide a clear rationale for the decision and the need for the intervention.
C. Discussing inappropriate behavior is not appropriate while the client is in seclusion and may exacerbate agitation.
D. Fluids should be offered more frequently than every 2 hours during seclusion to ensure hydration and comfort.
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