The nurse is caring for a preschool aged child immediately following an open repair of a Ventricular Septal Defect. There has been no drainage from the mediastinal chest tubes in the last 2 hours. Based on this finding what will be the nurse's priority intervention?
Document the Information as this is an expected finding.
Encourage the child to cough, and deep breathe
Immediately report this finding as this is life threatening
Assist the child to a sitting position to prove drainage
The Correct Answer is C
A. Documenting the information without taking action is inappropriate as lack of drainage could indicate a serious complication.
B. Encouraging the child to cough and deep breathe might be beneficial, but immediate reporting of this finding is critical.
C. Lack of drainage from the chest tubes following cardiac surgery can be life-threatening, indicating possible cardiac tamponade or tube occlusion. Immediate reporting is necessary for prompt intervention.
D. Assisting the child to a sitting position is not the priority; immediate evaluation by the healthcare team is required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This statement is incorrect as current research shows no credible evidence linking immunizations to autism.
B. While it might be necessary to have documentation if a parent refuses immunizations, this is not the most effective first response to the mother's concerns.
C. While it is true that parents have the right to make decisions regarding immunizations, this response does not address the mother's specific concern about autism.
D. Providing accurate, evidence-based information is the best first response. It addresses the mother's concerns directly and helps correct misinformation.
Correct Answer is C
Explanation
A. Documenting the information without taking action is inappropriate as lack of drainage could indicate a serious complication.
B. Encouraging the child to cough and deep breathe might be beneficial, but immediate reporting of this finding is critical.
C. Lack of drainage from the chest tubes following cardiac surgery can be life-threatening, indicating possible cardiac tamponade or tube occlusion. Immediate reporting is necessary for prompt intervention.
D. Assisting the child to a sitting position is not the priority; immediate evaluation by the healthcare team is required.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.