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 A
Explanation
The correct answer is choice A. Limit oral feedings to 30 min in length.
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in the prone position can compromise the respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.
Correct Answer is B
Explanation
The correct answer is choice B. Fish. Fish is a good source of protein and omega-3 fatty acids, which can help lower blood pressure, reduce inflammation, and prevent blood clots. Fish is also low in sodium, which is important for people with hypertension, as excess sodium can raise blood pressure by retaining fluid in the body. Fish is part of the DASH diet, which stands for Dietary Approaches to Stop Hypertension, and is a healthy eating plan that emphasizes fruits, vegetables, whole grains, low-fat dairy, nuts, seeds, legumes, and lean meats.
Choice A. Cheese is wrong because cheese is high in sodium and saturated fat, which can increase blood pressure and cholesterol levels.
Cheese should be limited or avoided by people with hypertension.
Choice C. Red meat is wrong because red meat is also high in sodium and saturated fat, as well as cholesterol, which can contribute to hypertension and heart disease.
Red meat should be eaten sparingly or replaced by leaner sources of protein like fish, poultry, or beans.
Choice D. Canned black beans are wrong because canned black beans are high in sodium, as most canned foods are preserved with salt. Canned black beans should be rinsed well before eating or replaced by dried or cooked black beans, which are lower in sodium and high in fiber, potassium, magnesium, and calcium, which are beneficial for blood pressure control.
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