Practice Question
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?
Answer Choices:
Correct Answer:
Immediately report this finding as this is life threatening
Rationale:
🚨 No drainage from chest tubes for 2 hours after open heart surgery may indicate tamponade or obstruction, both are surgical emergencies.
🚨 The nurse must immediately notify the provider, as fluid may be accumulating in the pericardial space, compressing the heart.
🚨 Tamponade presents with signs like hypotension, muffled heart sounds, and poor perfusion, and requires urgent intervention.
🚨 This is not expected and should never be documented as normal postoperatively.
🚨 Coughing or positioning may be used for minor blockages after physician notification, not as first actions.
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This question is from RN ATI Pediatrics Nurs 243 Exam which contains 33 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 4