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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. This is typical behavior for an 18-month-old toddler. They often play alongside others without interacting directly.
B. This is a normal developmental milestone for an 18-month-old child.
C. An 18-month-old child should be able to walk independently. Difficulty walking with assistance could indicate a potential developmental delay.
D. While vocabulary varies, most 18-month-olds can say a few words. This is within the normal range.

A. "My child will need to double his medications for the next 6 months." B. "My child will need to repeat his childhood immunizations once he is in remission." C. "I will ensure that my child is tested for tuberculosis every year." D. "The risk of transmission decreases once my child is on zidovudine fc

Correct Answer is C

Explanation

A. This statement indicates a misunderstanding of HIV medication management. Medication regimens are carefully tailored and adjusted as needed, but doubling the dose without medical advice is dangerous.
B. There is no cure for HIV, and "remission" is not a term used in this context. Additionally, some live vaccines are contraindicated in immunocompromised individuals, including those with HIV.
C. People with HIV are at increased risk of tuberculosis. Regular TB testing is crucial for early detection and treatment.
D. While antiretroviral therapy (ART) can significantly reduce the viral load and risk of transmission, it doesn't eliminate the risk entirely. Consistent use of condoms and other prevention methods is still essential.

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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?

Nursing Test Bank

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