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 A

Explanation

A. Avoiding further palpation of the abdomen is crucial to prevent rupture of the tumor and potential spread of cancer cells.
B. Obtaining an accurate height and weight is important but not as critical as preventing tumor rupture.
C. Monitoring vital signs is essential but not the priority intervention in this context.
D. Assessing the urine for the presence of blood is important for overall assessment but not the most critical intervention compared to avoiding tumor rupture.

A. Use of consistent caregivers B. Overstimulation C. Illness and pain D. Changes in the child's routine E. Providing short simple instructions

Correct Answer is ["B","C","D"]

Explanation

A. Use of consistent caregivers is beneficial for children with Autism Spectrum Disorder as it provides stability and predictability.
B. Overstimulation from the environment (e.g., noise, lights, activity) can lead to anxiety and frustration in children with Autism Spectrum Disorder.
C. Illness and pain are distressing and can increase anxiety and frustration, especially if the child has difficulty communicating their discomfort.
D. Changes in the child's routine can be particularly unsettling and may lead to anxiety and frustration.
E. Providing short, simple instructions helps in clear communication and reduces confusion, which can minimize anxiety.

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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

For a child diagnosed with a Wilm's tumor. The nurse recognizes that which of the following is MOST important intervention when planning care for this child?

Correct Answer is A

Explanation

The nurse is caring for a child with Autism Spectrum Disorder. The nurse recognizes that which of the following may trigger anxiety and frustration during the hospitalization? SELECT ALL THAT APPLY

Correct Answer is ["B","C","D"]

Explanation

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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?

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