A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

A. Wearing an N95 respiratory mask is not typically required for routine care of a toddler with respiratory syncytial virus unless performing procedures that generate aerosols.

B. Negative pressure rooms are generally reserved for patients with airborne infections like

tuberculosis; respiratory syncytial virus does not typically require isolation in a negative pressure room.

C. Using a designated stethoscope helps prevent the spread of infection to other patients by avoiding cross-contamination.

D. Removing the disposable gown after leaving the toddler's room is appropriate for maintaining infection control but is not specific to caring for a toddler with respiratory syncytial virus.

A.

A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.

B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.

C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.

D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.