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 C
Explanation
A. Hypotension is not a common adverse effect of cefazolin. While hypotension can occur in severe allergic reactions, it is not a typical side effect of this medication.
B. Prolonged wound healing is not a primary concern with cefazolin. This antibiotic does not typically affect wound healing directly.
C. Stevens-Johnson syndrome is correct. Cefazolin can cause serious skin reactions, including Stevens-Johnson syndrome, which is a severe, life-threatening condition characterized by blistering and peeling of the skin. The nurse should monitor for signs of this reaction.
D. Bradypnea is not a common adverse effect of cefazolin. Respiratory depression is not typically associated with this medication.
Correct Answer is B
Explanation
Rationale:
A. Capillary refill time of 3 seconds is within the normal range (less than 3 seconds) and does not indicate severe dehydration.
B. A sunken anterior fontanel is a significant sign of dehydration in infants and suggests severe dehydration.
C. While a weight loss of 5% can indicate dehydration, it may not necessarily represent severe dehydration. The extent of dehydration is better assessed by clinical signs such as fontanel status, skin turgor, and mucous membrane moisture.
D. Producing tears when crying is a reassuring sign and suggests adequate hydration, so it does not indicate severe dehydration.
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