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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assessing the client's mental status is crucial before administering zolpidem, a sleep aid, as it helps ensure the client is alert enough to take the medication safely. This assessment includes evaluating the client's level of consciousness, orientation, and cognitive function.
B. Monitoring body temperature might be necessary in certain clinical situations, but it's not directly relevant before administering zolpidem unless there are specific concerns related to body temperature.
C. Assessing bowel sounds is an important part of a comprehensive physical assessment, but it's not directly tied to the administration of a sleep aid like zolpidem.
D. Evaluating skin integrity is important for overall patient care, but it's not specifically linked to the assessment needed before administering a sleep medication like zolpidem.
Correct Answer is D
Explanation
A. Ask about pain. This is not the most important action because pain is not the primary problem in this situation. Pain may or may not be present, but it does not address the underlying cause of cyanosis.
B. Provide mouth care. This is not the most important action because mouth care does not improve oxygenation. Mouth care may be helpful to prevent infection and promote comfort, but it is not a priority in this case.
C. Offer fluids. This is not the most important action because fluids do not increase oxygen levels in the blood. Fluids may be beneficial to prevent dehydration and maintain circulation, but they are not urgent in this scenario.
D. Administer oxygen. This is the most important action because oxygen is essential for cellular function and survival. Oxygen therapy can reverse hypoxia and improve the client's condition.
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