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.
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Related Questions
Correct Answer is A
Explanation
Rationale:
A. This is a positive reinforcement strategy that can motivate the child to take the medication and reduce the unpleasant taste.
B. Giving milk with the medication may not be suitable for all medications, and some medications may interact with dairy products.
C. Mixing the medication with the child's favorite food is not advised because it can alter the taste and texture of the food and make the child dislike it in the future.
D. Diluting the medication with water may not be appropriate for all medications, and it could alter the effectiveness or stability of the medication.
Correct Answer is ["A","B","C","F","H"]
Explanation
Rationale:
A.Clients with sickle cell disease are at increased risk for infections, including those caused by pneumococcus. Ensuring vaccination status helps prevent future complications.
B. Folic acid supplementation may be part of the overall management of sickle cell disease, but it is not a priority intervention during a vaso-occlusive crisis.
C. Vaso-occlusive crises can lead to tissue hypoxia due to impaired blood flow.
Continuous monitoring of oxygen saturation helps in assessing tissue perfusion and detecting hypoxemia early.
D. Placing the client on strict bed rest can increase the risk of thrombosis and impair circulation.
E.Cold can cause vasoconstriction, worsening the pain and sickling process. Warm compresses are more appropriate for promoting comfort and improving circulation.
F. Meperidine (Demerol) is a potent opioid analgesic that can help alleviate severe pain associated with vaso-occlusive crises.
G. The nurse should not restrict oral intake, as hydration is important to prevent dehydration and further sickling.
H. Hydroxyurea is used to prevent vaso-occlusive crises in patients with sickle cell disease but is not typically administered during an acute crisis. This is a medication that reduces the frequency and severity of vaso-occlusive crises by increasing the production of fetal hemoglobin, which prevents sickling.
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