A nurse on a pediatric intensive care unit is caring for a toddler who weighs 12 kg (26.5 lb) and is postoperative following open heart surgery. Which of the following findings should the nurse report to the provider?
Drainage from the chest tube of 22 mL in the last hour
Urine output of 15 mL in the last 2 hr
Skin temperature 36° C (96.8° F)
Pedal and posterior tibial pulses of 2+
The Correct Answer is B
Rationale:
A. This amount of drainage may be expected postoperatively, and it is not indicative of a significant issue.
B. This is a concerning finding indicating possible inadequate renal perfusion, especially considering the postoperative status of the toddler.
C. While slightly lower than the typical body temperature, it is not necessarily abnormal, particularly in a postoperative setting.
D. Pulses of 2+ indicate adequate perfusion and are not concerning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Tachypnea (rapid breathing) is a common clinical manifestation of heart failure due to decreased cardiac output and inadequate tissue perfusion.
B. Tremors are not typically associated with heart failure.
C. Increased appetite is not typically associated with heart failure and may even be decreased due to symptoms such as fatigue and dyspnea.
D. Bradycardia (slow heart rate) is not typically associated with heart failure; instead, tachycardia (rapid heart rate) may occur as a compensatory mechanism.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Cyanosis can occur in children with heart failure due to inadequate oxygenation of tissues.
B. Weight gain or fluid retention is more common in children with heart failure.
C. Bounding pulses are more commonly associated with conditions such as hypertension or hyperthyroidism, rather than heart failure.
D. Dyspnea, or difficulty breathing, is a common symptom of heart failure due to fluid buildup in the lungs.
E. Tachycardia, or a rapid heart rate, can occur as a compensatory mechanism in response to decreased cardiac output in heart failure.
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