A 2-day-old infant with hydrocephalus returns from surgery following placement of a ventriculoperitoneal shunt. Which nursing intervention(s) should the practical nurse (PN) implement during postoperative care? (Select all that apply.)
Measure head circumference dally.
Document strict intake and output.
Irrigate shunt and pump valve every 12-hours.
Monitor body temperature every 4-hours.
Correct Answer : A,B,D
A. Measure head circumference daily. - Monitoring head circumference is crucial to detect changes that might indicate increased intracranial pressure after the shunt placement.
B. Document strict intake and output. - Monitoring fluid intake and output helps assess the infant's hydration status and shunt functionality.
C. Irrigate shunt and pump valve every 12-hours. - Shunt irrigation should be performed by specialized healthcare professionals, not typically by a practical nurse.
D. Monitor body temperature every 4 hours. - Postoperative monitoring includes assessing for signs of infection or systemic changes, which might be indicated by changes in body temperature.
E. Place in Trendelenburg position. - The Trendelenburg position is not typically recommended post-ventriculoperitoneal shunt placement and should be avoided unless specifically prescribed by the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Obliterating the entry could make the record look messy and might not meet documentation standards.
B. Notifying the charge nurse might be appropriate for major errors or if the policy requires it, but it might not be necessary for a simple correction like this.
C. Drawing a single line through the erroneous entry and inserting the correct information maintains the integrity of the chart and shows the correction clearly.
D. Charting the correct information in the next column might create confusion about the sequence of data and might not clearly indicate the correction made.
Correct Answer is A
Explanation
A. Determining the means of evacuation requires understanding the facility's evacuation protocols, coordinating with authorities, and ensuring the safety of residents, which typically falls under the responsibility of the nursing staff, including the practical nurse (PN).
B. Closing fire doors and residents' room doors can be part of fire safety protocols and may involve the immediate safety response handled by both nursing staff and facility personnel.
C. Assisting wandering residents and offering comfort and reassurance to distraught residents can be tasks shared among nursing and support staff to ensure resident safety and well-being during an emergency situation.
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