A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?

Irritability when being held

Heart rate 122/min

Hypoactive bowel sounds

Urine specific gravity 1.018

Answer and Explanation

The Correct Answer is A

A. Irritability when being held may indicate increased intracranial pressure or complications related to the VP shunt placement and should be reported to the provider.

B. A heart rate of 122/min is within the normal range for an infant and does not require reporting.

C. Hypoactive bowel sounds may occur postoperatively, especially if the infant has not been fed or has been under anesthesia, and is not an immediate concern.

D. A urine specific gravity of 1.018 is within normal limits for infants and does not indicate a need for reporting.

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Correct Answer is C

Explanation

A. Compensated metabolic acidosis would show a normal pH with a decrease in HCO3- and a decrease in PaCO2.

B. Compensated respiratory acidosis would show a normal pH with an elevated PaCO2 and a compensatory increase in HCO3-.

C. The low pH indicates acidosis, and the elevated PaCO2 suggests that it is respiratory in origin, with the HCO3- remaining normal, indicating no compensation has occurred yet.

D. Uncompensated metabolic acidosis would present with a low pH, low HCO3-, and normal PaCO2.

A. Select a quiet location to talk to the client while remaining visible to staff members. B. Give the client several clear options. C. Observe the client and the situation. D. Respect the client's personal space.

Correct Answer is C

Explanation

A. Selecting a quiet location is important, but first, it is essential to assess the client's current state and the surrounding environment.

B. Providing options can help empower the client, but it is best to first observe the client to gauge their level of agitation and determine the appropriate response.

C. Observing the client and the situation allows the nurse to understand the severity of the agitation and the context, which is critical for making informed decisions about the next steps.

D. Respecting personal space is important, but it should follow an assessment of the situation to ensure safety for both the client and staff.

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A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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