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. Explain in simple terms how it works.
Choice A rationale:
Asking the girl why she wants to know might be appropriate in some contexts, but children are naturally curious and seeking information is a common behavior. Explaining how the blood pressure apparatus works would likely be more beneficial than questioning her motivation.
Choice B rationale:
Determining why she is anxious assumes that the girl is anxious, which might not be the case. Additionally, the question she asked does not necessarily indicate anxiety, but rather a curiosity about the medical equipment.
Choice C rationale:
Explaining in simple terms how the blood pressure apparatus works is the most appropriate nursing action. This approach respects the child's curiosity and provides her with age-appropriate information, fostering a positive and educational interaction.
Choice D rationale:
Telling her that she will see how it works as it is used might not fully satisfy her curiosity or address her immediate question. Children often benefit from clear and concise explanations, especially when it comes to medical equipment.
Correct Answer is C
Explanation
The correct answer is choice C: Administering penicillin.
Choice A rationale:
Imposing strict bed rest for 4 to 6 weeks. This choice is not the most appropriate therapeutic management for rheumatic fever. While rest is important during the acute phase, strict bed rest for 4 to 6 weeks is excessive and could lead to physical deconditioning and psychological distress for the child.
Choice B rationale:
Administering corticosteroids if chorea develops. This choice is relevant to the management of rheumatic fever but is not the primary treatment. Chorea is a movement disorder that can occur as a complication of rheumatic fever. Corticosteroids may be used to manage chorea symptoms, but they are not the mainstay of treatment for rheumatic fever itself.
Choice C rationale:
Administering penicillin. This is the correct choice. Penicillin is the mainstay of treatment for rheumatic fever. It helps eradicate the group A streptococcal infection that triggers the inflammatory response leading to rheumatic fever. Penicillin is essential to prevent further complications such as rheumatic heart disease.
Choice D rationale:
Avoiding salicylates (aspirin). This choice is also relevant to the management of rheumatic fever. Salicylates, including aspirin, are used to relieve symptoms and reduce inflammation. However, in children with acute rheumatic fever, salicylates are contraindicated due to the risk of developing Reye's syndrome, a serious condition that affects the brain and liver.
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