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 ["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
Correct Answer is ["A","B","D"]
Explanation
The correct answers are choices A, B, and D.
Choice A rationale:
Decreased urinary output can be a sign of heart failure, especially in infants. In heart failure, the heart's ability to pump effectively can lead to decreased blood flow to the kidneys, resulting in decreased urine production.
Choice B rationale:
Sweating (inappropriate) is a symptom of heart failure in infants. Infants with heart failure might sweat excessively, especially while feeding or crying, due to the effort required by the heart to pump blood effectively.
Choice C rationale:
Warm flushed extremities are not typically associated with heart failure in infants. In heart failure, extremities might actually become cool and pale due to poor circulation.
Choice D rationale:
Anorexia, or a lack of appetite, is a common sign in infants with heart failure. The increased effort required for feeding due to compromised cardiac function can lead to poor feeding and decreased appetite.
Choice E rationale:
Weight loss can occur in infants with heart failure due to inadequate caloric intake, difficulty with feeding, and increased metabolic demands associated with heart failure. However, it's not as specific a sign as decreased urinary output, sweating, and anorexia.
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