A nurse is caring for a school-age child who weighs 20 kg (44 lb) and is postoperative with chest tubes in place. Which of the following findings should the nurse report to the provider?

Respiratory rate 22/min

Chest tube drainage of 200 mL in 1 hr

Serous chest tube drainage

Fluctuation in water-sealed chamber

Answer and Explanation

The Correct Answer is B

A.   This is within the normal range for a school-age child and does not require immediate reporting.
B.   This is a significant amount of drainage and should be reported to the provider as it may indicate ongoing bleeding or fluid accumulation.
C.   Serous drainage is expected in the early postoperative period and does not require immediate reporting.
D.   Fluctuation in the water-sealed chamber is normal and indicates that the chest tube system is functioning correctly.

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Correct Answer is ["A"]

Explanation

Given the child's recent motor vehicle accident and subsequent orthopedic surgeries, assessing the peripheral circulation is crucial. Comparing pedal pulses helps to determine the adequacy of blood flow to the lower extremities and identify any potential complications such as compartment syndrome. This assessment should be prioritized immediately.

While assessing pain, sedation level, and rechecking temperature are all important, they do not take precedence over assessing the child's circulation and perfusion status following major orthopedic surgeries.

A. Heart rate 54/min B. Flushing of the face C. Continuous swallowing D. Blood pressure 95/56 mm Hg

Correct Answer is C

Explanation

A. This heart rate is within the normal range for a child and does not indicate hemorrhage.
B. Flushing of the face can be caused by various factors and is not a specific sign of hemorrhage.
C. Frequent swallowing after a tonsillectomy can be a sign of post-operative bleeding as the child tries to clear blood from the throat.
D. This blood pressure is within the normal range for a child and does not indicate hemorrhage.

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A nurse is caring for a school-age child who weighs 20 kg (44 lb) and is postoperative with chest tubes in place. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A"]

Explanation

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