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 B

Explanation

A. Lotions, powders, or ointments should be avoided under the harness as they can irritate the skin.
B. This helps protect the skin and keeps the harness clean.
C. Only a healthcare provider should adjust the harness straps. Parents should not attempt to do this.
D. Massage can irritate the skin and should be avoided.

A. Remove the inhaler from the mouth. B. Depress the canister while inhaling slowly. C. Hold breath for 10 seconds. D. Exhale slowly through the nose.

Correct Answer is D,B,C,A

Explanation

D. Before using the inhaler, the child should exhale fully to empty the lungs and ensure that the medication can be effectively inhaled. This step prepares the airways to receive the medication.

B. As the child starts to inhale slowly and deeply through the mouthpiece, they should simultaneously depress the canister to release the medication. This coordinated action ensures that the medication is delivered into the lungs.

C. After inhaling the medication, the child should hold their breath for about 10 seconds (or as long as comfortable). This allows the medication to settle in the airways and improves its effectiveness.

A. After holding the breath, the child can remove the inhaler from their mouth. This step concludes the inhalation process and allows the child to exhale normally.

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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

Naxlex Comprehensive Predictor Exams

A nurse is planning care for an infant who has a prescription for a Pavlik harness. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is teaching a child who has asthma about using a metered-dose inhaler with a mouthpiece. Identify the sequence of steps the nurse should instruct the child to take. (Move the steps below into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is D,B,C,A

Explanation

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