A nurse is caring for a school-age child who weighs 20 kg (44 lb) and is postoperative with chest tubes in place. Which of the following findings should the nurse report to the provider?
Respiratory rate 22/min
Chest tube drainage of 200 mL in 1 hr
Serous chest tube drainage
Fluctuation in water-sealed chamber
The Correct Answer is B
A. This is within the normal range for a school-age child and does not require immediate reporting.
B. This is a significant amount of drainage and should be reported to the provider as it may indicate ongoing bleeding or fluid accumulation.
C. Serous drainage is expected in the early postoperative period and does not require immediate reporting.
D. Fluctuation in the water-sealed chamber is normal and indicates that the chest tube system is functioning correctly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This is within the normal range for a school-age child and does not require immediate reporting.
B. This is a significant amount of drainage and should be reported to the provider as it may indicate ongoing bleeding or fluid accumulation.
C. Serous drainage is expected in the early postoperative period and does not require immediate reporting.
D. Fluctuation in the water-sealed chamber is normal and indicates that the chest tube system is functioning correctly.
Correct Answer is B
Explanation
A. Factor VIII concentrate is used to treat hemophilia, not iron deficiency anemia.
B. Ferrous sulfate is an iron supplement commonly used to treat iron deficiency anemia.
C. Good oral hygiene is important but it does not directly address the underlying issue of iron deficiency anemia.
D. There is no need for protective precautions in iron deficiency anemia.
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