Ati nurs 243 paediatrics proctored exam
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?
Explanation & Rationale
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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