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. Abstinence is the only guaranteed way to prevent STIs.
B. Early detection and treatment of STIs can prevent serious health problems, including infertility, pelvic inflammatory disease, and chronic pain.
C. While having one faithful partner who is also only with you reduces the risk, it doesn't eliminate it completely. New partners can introduce STIs.
D. Adolescents are at increased risk for STIs due to various factors, including hormonal changes, experimentation, and lack of consistent condom use.
Correct Answer is C
Explanation
A. Increasing oral fluid intake would not necessarily improve dialysate outflow. This could worsen the issue if the problem is related to fluid overload.
B. Increasing dwell time might allow more time for fluid and waste removal, but it's not the most appropriate action in this case. The primary concern is the lack of outflow, which suggests a potential obstruction or other issue.
C. Changing the child's position can help to reposition the catheter and improve drainage. This is a reasonable action to try.
D. A bruit indicates increased blood flow to the area. While it's important to assess for this, it's not the most immediate action to take.
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