The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the most appropriate initial nursing action?
Place the child in the Trendelenburg position.
Apply a new bandage with more pressure.
Notify the physician.
Apply direct pressure above the catheterization site.
The Correct Answer is D
Answer is: d. Apply direct pressure above the catheterization site.
Explanation: The first action should be to apply direct pressure above the catheterization site to help control the bleeding and minimize blood loss. This will also give the nurse time to prepare additional interventions or supplies if necessary.
Choice a. is wrong because placing the child in the Trendelenburg position is not an appropriate initial nursing action in this scenario. This position can increase intracranial pressure and is typically used for patients experiencing shock or hypotension.
Choice b. is wrong because applying a new bandage with more pressure might be a subsequent action, but the priority is to apply direct pressure to slow down the bleeding.
Choice c. is wrong because notifying the physician is important, but the nurse should first take immediate action to control the bleeding and minimize potential harm to the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Asthma.
Choice A rationale:
A foreign body in the trachea can cause acute respiratory distress and a sudden cough, but it is unlikely to cause chronic nonproductive cough and diffuse wheezing during the expiratory phase of respiration. The symptoms in the scenario are more suggestive of a chronic condition.
Choice B rationale:
Bronchiolitis primarily affects infants and young children, causing symptoms such as fever, rhinorrhea, and wheezing. While wheezing can be present, the diffuse wheezing during the expiratory phase described in the scenario is more characteristic of asthma.
Choice C rationale:
Asthma is characterized by chronic inflammation of the airways, leading to episodes of bronchoconstriction and increased airway reactivity. The chronic, nonproductive cough and diffuse wheezing during the expiratory phase are classic signs of asthma. Expiratory phase wheezing occurs due to the narrowing of the smaller airways during expiration.
Choice D rationale:
Pneumonia is an infection of the lung tissue and can cause productive cough, fever, and crackles on auscultation. While wheezing might occur in pneumonia due to inflammation and narrowing of the airways, it's not the most likely cause of the symptoms described in the scenario.
Correct Answer is ["954.5"]
Explanation
Step 1 is converting the child's weight from pounds to kilograms. (42 lb ÷ 2.2) = 19.09090909 kg
Step 2 is calculating the maximum daily dosage using the upper limit of the dosage range (50 mg/kg/day). 19.09090909 kg × 50 mg/kg/day = 954.5454545 mg/day
Step 3 is rounding the result to the nearest tenth. The answer is 954.5
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.