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. The most appropriate initial nursing action is to:
A)Notify the physician.
B)Apply a new bandage with more pressure.
C)Place in the Trendelenburg position.
D)Apply direct pressure above the catheterization site.

Question

Quizplus · Accepted Answer

If bleeding occurs,direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying the physician and applying a new bandage with more pressure can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. The Trendelenburg position would not be helpful;it would increase the drainage from the lower extremities.

The Nurse Is Caring for a School-Age Girl Who Has