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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Determine the means by which residents will be evacuated. - This task requires critical decision-making and understanding of evacuation protocols, which is within the scope of the practical nurse's responsibilities.
B. Close all fire doors and the doors to all the residents' rooms. - While important for containment, this can be executed by UAP following established protocols.
C. Assist any wandering residents back to their rooms. - UAP can assist in guiding residents back to their rooms safely.
D. Offer comfort and reassurance to distraught residents. - Both PN and UAP can offer comfort and reassurance to residents during such situations.

A. Insert lubricated tip of tubing 3 to 4 inches into the rectum. B. Position client in left lateral recumbent position to expose buttocks. C. Chill the enema solution to help reduce the client's fever. D. Encourage client to retain solution for at least 5 minutes. E. Clamping the enema administration tubing

Correct Answer is ["A","B","D","E"]

Explanation

A. Inserting the lubricated tip of the tubing 3 to 4 inches into the rectum allows for the proper administration of the enema.
B. Positioning the client in the left lateral recumbent position helps expose the rectum for the enema administration.
C. Chilling the enema solution isn't recommended as it might cause discomfort or shock to the client.
D. Encouraging the client to retain the solution for at least 5 minutes helps ensure effectiveness.

E. Clamping the enema administration tubing after filling the enema bag helps control the flow during the procedure.

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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.)

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Naxlex Comprehensive Predictor Exams

When a small fire breaks out in the kitchen of a long-term care facility, which task should be performed by the practical nurse (PN) rather than the unlicense assistive personnel (UAP)?

Correct Answer is A

Explanation

The practical nurse (PN) is administering a saline enema to a client who was admitted because of a fever of unknown origin and is now constipated. Which techniques should the PN use? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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