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 A
Explanation
A. Shakiness is a common symptom of hypoglycemia. When blood glucose levels drop, the body may react with symptoms like trembling or shaking. This is because low blood sugar levels can trigger the release of adrenaline, leading to physical symptoms such as shakiness.
B. While decreased appetite can occur in various conditions, it is not a primary or specific manifestation of hypoglycemia. Typically, hypoglycemia causes symptoms related to the body’s response to low glucose levels, such as shakiness, sweating, or confusion, rather than a decrease in appetite.
C. Thirst is more commonly associated with hyperglycemia (high blood glucose levels), not hypoglycemia. When blood glucose levels are high, the body tries to get rid of the excess sugar through increased urination, leading to dehydration and increased thirst. This is not a typical sign of low blood sugar.
D. Increased capillary refill time is generally a sign of poor perfusion or dehydration and is not specific to hypoglycemia. In hypoglycemia, the capillary refill time is usually normal, though other signs such as shakiness, sweating, or irritability are more indicative of low blood sugar levels.
Correct Answer is ["12.5"]
Explanation
Convert pounds to kilograms
1 lb is approximately 0.453592 kg
55 lb * 0.453592 kg/lb = 24.94756 kg
Dose = weight in kg * prescribed dose
Dose = 24.94756 kg * 10 mg/kg = 249.4756 mg
The ibuprofen solution is 100 mg/5 mL To find the volume for 249.4756 mg:
(249.4756 mg / 100 mg) * 5 mL = 12.47378 mL
12.47378 mL ≈ 12.5 mL
Therefore, the nurse should administer 12.5 mL of ibuprofen.
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