The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with blood
The most appropriate initial nursing action is to:
a. notify physician.
b. apply new bandage with more pressure.
c. place the child in Trendelenburg position.
d. apply direct pressure above catheterization site.
ANS: D
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 a physician and applying a new bandage can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It would increase the drainage from the lower extremities.
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