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. Isolate the client from staff who are pregnant.
Choice A rationale: Aspirin should not be administered to children or adolescents with viral infections like rubella due to the risk of Reye's syndrome, a potentially fatal condition that causes liver and brain damage.
Choice B rationale: Rubella (German measles) is particularly dangerous for pregnant women because it can cause congenital rubella syndrome in the fetus, leading to severe birth defects. Therefore, isolating the client from pregnant staff is crucial to prevent exposure.
Choice C rationale: Airborne precautions are not necessary for rubella. Rubella is transmitted through respiratory droplets, so droplet precautions, not airborne precautions, are appropriate.
Choice D rationale: Koplik spots are associated with measles (rubeola), not rubella. Therefore, monitoring for Koplik spots is not relevant for a client with rubella.
Correct Answer is A
Explanation
The correct answer is choice A, hematuria.
Hematuria is the presence of red blood cells in the urine, which can make it appear pink or cola-colored. Hematuria is a common sign of glomerulonephritis, which is inflammation of the tiny filters in the kidneys (glomeruli) that remove waste and excess fluid from the blood.
Hematuria occurs because the inflamed glomeruli allow some blood cells to leak into the urine.
Choice B, polyuria, is wrong because polyuria is the production of abnormally large amounts of urine. Polyuria is not a typical feature of acute glomerulonephritis, which may actually cause reduced urine output due to fluid retention and decreased kidney function.
Choice C, weight loss, is wrong because weight loss is not a common symptom of acute glomerulonephritis. On the contrary, weight gain may occur due to fluid retention and edema (swelling) in the face, hands, feet and abdomen.
Choice D, hypotension, is wrong because hypotension is low blood pressure. Hypotension is not usually associated with acute glomerulonephritis, which may cause high blood pressure (hypertension) due to fluid overload and impaired sodium excretion by the kidneys.
Normal ranges for blood pressure are less than 120/80 mmHg for adults.
Normal ranges for urine output are about 800 to 2000 mL per day for adults.
Normal ranges for protein in the urine are less than 150 mg per day for adults. Normal ranges for red blood cells in the urine are less than 3 per high-power field for men and less than 5 per high-power field for women.
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