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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Prednisolone suppresses the immune system, which can impair the body's ability to heal wounds.
B. Prednisolone is more likely to cause hypertension (high blood pressure) due to fluid retention.
C. Stevens-Johnson syndrome is a rare but severe allergic reaction that is not typically associated with prednisolone.
D. While long-term use of high-dose corticosteroids can potentially affect kidney function, it's not a common or immediate side effect.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
A. Educate the child about proper perineal hygiene. Anticipated. This is essential to prevent the recurrence of UTIs.
B. Advise child's guardian about the use of sunscreen. Anticipated. While not directly related to the UTI, protecting the child's skin from sun damage is important overall health.
C. Administer salicylic acid for pain and fever. Contraindicated. Salicylic acid is contraindicated in children due to the risk of Reye's syndrome.
D. Administer sulfamethoxazole and trimethoprim. Anticipated. This is the prescribed medication for the UTI and should be administered as ordered.
E. Ensure the child receives a maximum of 1,200 mL/day of fluid. Anticipated. Adequate hydration is crucial for flushing bacteria from the urinary tract. Restricting fluids is counterproductive.
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