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 A
Explanation
The correct answer is choice A: "Urethral opening along ventral surface of penis."
Choice A rationale:
The statement "Urethral opening along ventral surface of penis" is correct. Hypospadias is a congenital condition where the opening of the urethra is located on the underside of the penis rather than at the tip. This anomaly requires surgical correction.
Choice B rationale:
The statement "Urethral opening along dorsal surface of penis" is incorrect. This statement describes an anatomically incorrect condition. The opening of the urethra is not supposed to be along the dorsal surface of the penis.
Choice C rationale:
The statement "Absence of a urethral opening" is incorrect. This statement describes a more severe condition called "urethral agenesis" where the urethral opening is completely absent. Hypospadias is different and involves a misplaced urethral opening.
Choice D rationale:
The statement "Penis shorter than usual for age" is not related to hypospadias. Hypospadias primarily involves the location of the urethral opening and is unrelated to the length of the penis.
Correct Answer is C
Explanation
The correct answer is choice C: Oral rehydration solution (ORS).
Choice A rationale:
Clear liquids, 1 to 2 ounces at a time, might not be sufficient to adequately rehydrate a child with severe dehydration. Clear liquids lack the necessary electrolytes and glucose content to effectively combat dehydration and replace lost fluids.
Choice B rationale:
Administration of antidiarrheal medication is not the initial step in managing severe dehydration caused by acute diarrhea and vomiting. Antidiarrheal medications can slow down the gastrointestinal motility, which may exacerbate the problem by delaying the elimination of the causative agent and prolonging the dehydration.
Choice C rationale:
Oral rehydration solution (ORS) is the recommended initial intervention for managing severe dehydration caused by acute diarrhea and vomiting. ORS contains the appropriate balance of electrolytes (sodium, potassium, chloride) and glucose to replace lost fluids and electrolytes, thereby helping to rehydrate the child effectively. It is absorbed even when digestion is impaired due to the illness.
Choice D rationale:
Intravenous fluids might be necessary if the child's condition is very severe and oral intake cannot be maintained. However, it's not the first-line intervention. Oral rehydration is preferred whenever feasible because it is less invasive and can be administered even in mild to moderate dehydration cases.
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