Question

A nurse is caring for a 6-year-old who had a cardiac catheterization. During assessment of the groin site, the nurse notices that the dressing is saturated with blood and a small trickle leaks down the child's leg. What should the nurse's first action be?

1) Apply a new pressure dressing to the catheterization site
2) Call the health care provider (HCP)
3) Check the peripheral pulse distal to the catheterization site
4) Remove the dressing and apply direct pressure above the puncture site

Answer 1

The nurse's first action should be to remove the dressing and apply direct pressure above the puncture site. Additionally, checking the peripheral pulse and notifying the healthcare provider are important.

Step-by-step explanation:

The nurse's first action should be to remove the dressing and apply direct pressure above the puncture site. This is because a saturated dressing and blood trickle suggest active bleeding at the catheterization site. By removing the dressing and applying direct pressure, the nurse can control the bleeding and prevent further complications.

Additionally, the nurse should check the peripheral pulse distal to the catheterization site to assess the adequacy of blood flow to the extremity. This will help determine if any further intervention is required.

It is also important for the nurse to notify the healthcare provider about the bleeding and seek further guidance and orders for management.