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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Doing everything for the child may increase dependency and does not promote the child's development.
B. Assessing the child's level of mental maturity, self-help abilities, and habits helps the nurse to provide care that is appropriate to the child's developmental level and promotes independence.
C. Using chronological age alone does not consider the child's actual developmental abilities.
D. Speaking only to the mother ignores the child's ability to understand and participate in their own care, regardless of their level of disability.

Correct Answer is ["0.4"]

Explanation

To calculate the daily maintenance dose of digoxin for the infant, we first convert the ordered amount from micrograms to milligrams: 4 mcg/kg/day is equivalent to 0.004 mg/kg/day. For an infant weighing 5 kg, the daily dose would be 0.004 mg/kg/day * 5 kg = 0.02 mg/day. Now, using the concentration provided on the label, which is 0.25 mg/5 mL, we can find out how many milliliters would equate to the required daily dose. This is done by setting up a proportion: (0.25 mg / 5 mL) = (0.02 mg / X mL). Solving for X gives us X = (0.02 mg * 5 mL) / 0.25 mg, which equals 0.4 mL.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a child with an intellectual disability due to Down's Syndrome. The nurse understands that it is important to provide developmentally appropriate care. Which of the following will help to meet this need?

Correct Answer is B

Explanation

The nurse is preparing to administer the daily maintenance dose of digoxin to an infant: Infant's Weight: 5kg Order: Administer 4mcg/kg/day Safe Dose: 3.4 to 5.1 mcg/kg/day Label: 0.25 mg/5mL

Correct Answer is ["0.4"]

Explanation

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