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.
Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
Apply direct pressure to the puncture site.
Elevate the affected extremity above the level of the heart.
Leave the dressing undisturbed and notify the physician immediately.
The Correct Answer is B
The correct answer is choice B. Apply direct pressure to the puncture site.
Choice A rationale:
Applying intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site is not the best approach. This method may not effectively control the bleeding and could potentially dislodge the introducer sheath.
Choice B rationale:
Applying direct pressure to the puncture site is the most effective way to control bleeding. Direct pressure helps to promote clot formation and reduce blood flow to the area, which is crucial in managing postoperative bleeding.
Choice C rationale:
Elevating the affected extremity above the level of the heart is not appropriate in this situation. While elevation can reduce swelling, it does not address the immediate need to control active bleeding.
Choice D rationale:
Leaving the dressing undisturbed and notifying the physician immediately is not advisable. Immediate action to control the bleeding is necessary before notifying the physician. Delaying intervention could lead to significant blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Use an ibuterol inhaler.
Choice A rationale:
Completing oral hygiene is important for overall health, but it is not specifically related to the preparation for postural drainage in cystic fibrosis patients. Postural drainage is a technique used to clear mucus from the lungs, and oral hygiene does not directly affect this process.
Choice B rationale:
Using a bronchodilator, such as an ibuterol inhaler, is recommended before postural drainage because it helps to open the airways, making the drainage process more effective. Bronchodilators are often used to relax the muscles around the airways, which can become constricted in conditions like cystic fibrosis.
Choice C rationale:
Taking pancrelipase is related to aiding digestion in cystic fibrosis patients who have pancreatic insufficiency. While it is an important part of the overall management of cystic fibrosis, it is not directly related to the preparation for postural drainage.
Choice D rationale:
Eating a meal before postural drainage is not recommended because a full stomach can make the process uncomfortable and less effective. It is generally advised to perform postural drainage on an empty stomach to ensure that the mucus can be cleared from the lungs more easily.
Correct Answer is A
Explanation
The correct answer is A. I can lift objects that are less than 10 pounds.
Here's a breakdown of why the other options are incorrect:
- B. I can resume activities, such as sewing. - Sewing requires fine motor skills and close eye work, which can increase intraocular pressure and potentially worsen the detached retina.
- C. I can go jogging after 2 weeks. - Strenuous activities like jogging can increase blood pressure and strain the eye, potentially leading to another retinal detachment.
- D. I should bend at the waist when putting on my shoes. - Bending at the waist increases intraocular pressure and can strain the eye. It's recommended to sit down or use a stool to put on shoes.
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