The nurse notices that a child is increasingly apprehensive and has tachycardia after heart surgery.The chest tube drainage is now 8 ml/kg/hr.What should be the nurse's initial intervention?
A) Apply warming blankets.
B) Notify the practitioner of these findings.
C) Give additional pain medication per protocol.
D) Encourage child to cough, turn, and deep breathe.

Question

Quizplus · Accepted Answer

The practitioner is notified immediately.Increases of chest tube drainage to more than 3 ml/kg/hr for more than 3 consecutive hours or 5 to 10 ml/kg in any 1 hour may indicate postoperative hemorrhage.Increased chest tube drainage with apprehensiveness and tachycardia may indicate cardiac tamponade-blood or fluid in the pericardial space constricting the heart-which is a life-threatening complication.Warming blankets are not indicated at this time.Additional pain medication can be given before the practitioner drains the fluid,but the notification is the first action.Encouraging the child to cough,turn,and deep breathe should be deferred until after evaluation by the practitioner.

The Nurse Notices That a Child Is Increasingly Apprehensive and Has