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 nursing action is most appropriate to institute initially?
a. Notify the physician.
b. Place the child in Trendelenburg position.
c. Apply a new bandage with more pressure.
d. Apply direct pressure above the catheterization site.
ANS: D
When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure on the vessel puncture. The physician can be notified, and a new bandage with more pressure can be applied after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. Trendelenburg positioning would not be a helpful intervention. It would increase the drainage from the lower extremities.
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