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 C

Explanation

A. Calling the charge nurse might be necessary, but the immediate action after a needlestick injury is to cleanse the affected area to minimize the risk of infection.
B. Observing the appearance of the injection site is important but not the first action following a needlestick injury.
C. Cleaning the finger with soap and water is the initial action to reduce the risk of infection following a needlestick injury.
D. Explaining the occurrence to the client is important but comes after taking care of the nurse's immediate health following a needlestick injury.

A. Determine the means by which residents will be evacuated. B. Close all fire doors and the doors to all the residents' rooms. C. Assist any wandering residents back to their rooms. D. Offer comfort and reassurance to distraught residents.

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.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) administers an injection using a syringe with a retractable needle. After the needle is removed from the client's skin, the needle does not retract, and the PN gets stuck in the finger with the used needle. What action should the PN take first?

Correct Answer is C

Explanation

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 assisting with the preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?

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