Difficulty: Medium
Average Score: 94%
Simulated
Passage / Scenario
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?
Correct answer
B
Rationale
The correct answer is B: Chest tube drainage of 200 mL in 1 hr. This finding indicates excessive drainage which could be a sign of hemorrhage or other complications. The nurse should report this to the provider immediately for further assessment and intervention to prevent further complications.
A: Serous chest tube drainage is a normal finding and does not require immediate reporting.
C: Fluctuation in the water-sealed chamber is a normal finding indicating proper functioning of the chest drainage system.
D: Respiratory rate of 22/min is within normal range and does not require immediate provider notification.
Overall, choice B is the correct answer as it signifies a potentially serious issue that needs prompt attention.
A: Serous chest tube drainage is a normal finding and does not require immediate reporting.
C: Fluctuation in the water-sealed chamber is a normal finding indicating proper functioning of the chest drainage system.
D: Respiratory rate of 22/min is within normal range and does not require immediate provider notification.
Overall, choice B is the correct answer as it signifies a potentially serious issue that needs prompt attention.