An 18-month-old child returned from the cardiac cath lab 1/2 hour ago. The child wakes up and begins crying. The nurse notices that the pressure dressing is becoming saturated with blood. The nurse's first action should be to:
Remove the dressing to identify where the bleeding is coming from
Let the parent hold the child to calm him
Put direct pressure on the dressing to stop the bleeding
Draw up the ordered morphine to calm the child
The Correct Answer is C
Choice A reason: This is not a good choice. Removing the dressing to identify where the bleeding is coming from can increase the risk of infection and further bleeding. The nurse should keep the dressing in place and apply direct pressure to control the bleeding.
Choice B reason: This is not a good choice. Letting the parent hold the child to calm him can worsen the bleeding by increasing the blood pressure and heart rate. The nurse should keep the child in a supine position and reassure him while applying direct pressure to the dressing.
Choice C reason: This is the correct choice. Putting direct pressure on the dressing to stop the bleeding is the first and most effective action to take in this situation. The nurse should use a sterile gauze pad or a gloved hand to apply firm and continuous pressure to the dressing until the bleeding stops or medical assistance arrives.
Choice D reason: This is not a good choice. Drawing up the ordered morphine to calm the child is not the priority action in this situation. The nurse should first stop the bleeding and then assess the child's pain level and administer the appropriate analgesic. Morphine can also cause respiratory depression and hypotension, which can complicate the child's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as maceration is not a clinical manifestation of scabies, but a condition of softening and breaking down of the skin due to prolonged exposure to moisture. Maceration can occur in areas where the skin folds or rubs together, such as the groin, armpits, or under the breasts.
Choice B reason: This statement is incorrect, as edema is not a clinical manifestation of scabies, but a condition of swelling due to excess fluid accumulation in the tissues. Edema can occur in various parts of the body, such as the legs, feet, hands, or face, due to various causes, such as heart failure, kidney disease, or allergic reactions.
Choice C reason: This statement is correct, as itching is the primary clinical manifestation of scabies, a contagious skin infection caused by the mite Sarcoptes scabiei. The mite burrows into the skin and lays eggs, causing an intense inflammatory response and pruritus. The itching is usually worse at night and affects the areas between the fingers, wrists, elbows, armpits, waist, buttocks, and genitals.
Choice D reason: This statement is incorrect, as severe pain is not a clinical manifestation of scabies, but a subjective sensation of physical discomfort or distress. Pain can occur in various parts of the body due to various causes, such as injury, inflammation, infection, or disease. Pain can be acute or chronic, and can be rated on a scale of 0 to 10.
Correct Answer is B
Explanation
Choice A reason: This is not a good choice. Adult heart disease can cause volume overload, but so can pediatric heart disease. Volume overload is a condition where the heart has to pump more blood than normal, which can lead to heart failure and pulmonary edema. Volume overload can be caused by various factors, such as valvular defects, hypertension, or anemia.
Choice B reason: This is the correct choice. Adult heart disease is usually acquired, meaning that it develops over time due to factors such as aging, lifestyle, or infection. Pediatric heart disease is usually congenital, meaning that it is present at birth due to genetic or environmental factors that affect the development of the heart.
Choice C reason: This is not a good choice. Heart failure can occur in both adult and pediatric heart disease. Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs, which can lead to symptoms such as fatigue, shortness of breath, and edema. Heart failure can be caused by various factors, such as coronary artery disease, cardiomyopathy, or arrhythmias.
Choice D reason: This is not a good choice. Digoxin is a drug that can be used for both adults and children with heart disease. Digoxin is a cardiac glycoside that increases the force and efficiency of the heart contractions, slows down the heart rate, and improves the symptoms of heart failure. Digoxin can be used for conditions such as atrial fibrillation, heart failure, or congenital heart defects. However, digoxin has a narrow therapeutic range and requires careful monitoring of the blood levels and the patient's response.
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