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 D
Explanation
A. While it is important to check for skin irritation at the cast edges, this is not the most immediate concern compared to other potential complications. Skin irritation can occur, but it is a less urgent issue compared to signs of more serious problems like impaired circulation or swelling.
B. Itching is a common issue with casts, and using a hair dryer on a cool setting can help relieve this discomfort. However, this is a comfort measure and does not address the more critical aspects of cast care and potential complications.
C. Restricting strenuous activities is important to prevent complications and ensure proper healing, but it is not the most immediate concern following cast application. The timeframe may also need to be
longer than just 3 days, depending on the type of surgery and cast. Specific activity restrictions should be based on the child's condition and the surgeon's recommendations.
D. Monitoring for pallor and swelling is critical because these signs can indicate compromised circulation or other serious complications related to the cast. Swelling and changes in skin color can suggest that the cast is too tight or that there is a problem with blood flow. Immediate attention is needed if these symptoms are observed to prevent further complications.
Correct Answer is A
Explanation
A. Phototherapy can increase a newborn's body temperature. Frequent monitoring is essential to prevent overheating.
B. Mittens may be used but their use is not directly related to phototherapy.
C. Applying lotion can interfere with the effectiveness of phototherapy. The newborn's skin should be kept clean and dry.
D. The newborn's eyes should be checked more frequently, typically every 4 hours, to monitor for any irritation or inflammation caused by the light.
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