A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is effective?

 

 

 

A. The water seal chamber should contain at least 2 cm of water to maintain the seal and prevent air from entering the pleural space. Only 1 cm of water is inadequate and requires intervention.
B. Tidaling, or fluctuation of water with respirations, is an expected finding and indicates that the system is functioning properly.
C. A suction chamber pressure of -20 cm H₂O is the standard setting for chest tube drainage systems and does not require intervention.
D. A drainage collection chamber that is one-third full is within normal limits and simply indicates the need to continue monitoring output.

A. Failure to engraft is characterized by the absence of new bone marrow cell growth, leading to persistent low blood counts. It does not typically present with skin peeling or desquamation.

B. Veno-occlusive disease primarily affects the liver and presents with symptoms such as weight gain, hepatomegaly, and jaundice. Skin desquamation is not a common manifestation of this complication.

C. Graft-versus-host disease commonly affects the skin, liver, and gastrointestinal tract, with early signs including rash and desquamation of the hands and feet. This finding is a hallmark indication of this complication following a bone marrow transplant.

D. Pancytopenia involves a reduction in red blood cells, white blood cells, and platelets, leading to fatigue, infection risk, and bleeding. It does not typically cause skin peeling.