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 B
Explanation
The correct answer is choice B. A feeling of fullness in the ear.
Choice A rationale:
Nausea and vomiting are not typical symptoms of chronic otitis media with effusion (OME). OME involves fluid accumulation in the middle ear without signs of acute infection. It is commonly seen in children and may cause mild hearing impairment and a feeling of fullness in the ear.
Choice B rationale:
A feeling of fullness in the ear is a common symptom of OME. The fluid accumulation in the middle ear can lead to a sensation of pressure or fullness, as well as mild hearing loss. This can impact a child's ability to hear and communicate effectively.
Choice C rationale:
Severe pain in the ear is more characteristic of acute otitis media (AOM), which is an infection of the middle ear with signs of inflammation. In OME, pain is typically not a prominent symptom unless there is an underlying AOM episode.
Choice D rationale:
Fever as high as 40°C (104°F) is not a typical symptom of OME. OME is generally a chronic condition without acute signs of infection such as fever. However, if a fever is present, it might indicate a concurrent infection that needs further evaluation.
Correct Answer is C
Explanation
The correct answer is choice C. Crohn's disease.
Choice A rationale:
Ulcerative colitis is a chronic inflammatory disease that primarily affects the colon and rectum, causing continuous areas of inflammation and ulcers. It does not involve any part of the GI tract from mouth to anus as stated in the question.
Choice B rationale:
Meckel's diverticulum is a congenital condition where a small pouch forms in the lower part of the small intestine. It is not characterized by a chronic inflammatory process involving various parts of the GI tract.
Choice C rationale:
Crohn's disease is a chronic inflammatory disorder that can affect any part of the gastrointestinal tract from mouth to anus. It commonly causes inflammation, ulceration, and narrowing of the affected segments of the intestines. This inflammation can lead to a range of symptoms including abdominal pain, diarrhea, and weight loss. The question accurately describes Crohn's disease.
Choice D rationale:
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain or discomfort and changes in bowel habits. It is not associated with chronic inflammatory processes or ulceration as seen in Crohn's disease.
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.