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.
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Related Questions
Correct Answer is B
Explanation
A. While providing assistance with activities of daily living is important, ensuring the child's environment is safe is a higher priority to prevent injuries.
B. Modifying the home for safety is the priority because children with hemiplegic cerebral palsy have motor impairments that increase their risk for accidents and injuries. A safe environment is essential for the child’s well-being.
C. Providing respite services for the parents is beneficial for the family’s overall stress management, but it is not as immediate a concern as ensuring the child’s safety.
D. Improving communication skills is important for the child's overall development, but ensuring a safe living environment takes precedence to prevent potential harm.
Correct Answer is B
Explanation
A. This statement is not accurate as many daycare policies allow children to return after a shorter period if symptoms improve.
B. It is generally accepted that children with bacterial conjunctivitis can return to daycare after 24 to 48 hours of antibiotic treatment, as the risk of contagion is significantly reduced. Parents should confirm the specific policy with their daycare.
C. While waiting for symptoms to completely resolve is ideal, it is not the most practical or common recommendation.
D. Completing the full course of antibiotics is important for the child's health, but it is not necessary for returning to school.
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