A nurse is caring for a 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority?

Lethargy

Urine output 70 mL in 2 hr

Lying flat on the unaffected side

Respiratory rate 20/min

Answer and Explanation

The Correct Answer is A

A. Lethargy: Lethargy can be a concerning sign in a postoperative child, especially following a procedure involving the central nervous system like VP shunt insertion. It could indicate increased intracranial pressure or other neurological complications, which require immediate attention. Therefore, this is a priority finding.

B. Urine output 70 mL in 2 hr: While monitoring urine output is important for assessing hydration and renal function, a urine output of 70 mL in 2 hours may not be immediately concerning in a 4-year-old child. However, if this pattern continues or if there are signs of dehydration, it should be addressed. It's not as urgent as assessing for neurological changes.

C. Lying flat on the unaffected side: The positioning of the child, lying flat on the unaffected side, may or may not be concerning depending on the specific instructions provided postoperatively. While positioning can affect the function of the VP shunt, it may not necessarily indicate an immediate complication.

D. Respiratory rate 20/min: A respiratory rate of 20 breaths per minute is within the normal range for a 4-year-old child. While changes in respiratory rate can indicate respiratory distress, this respiratory rate alone is not immediately concerning.

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Correct Answer is B

Explanation

A. "I will elevate the affected area if possible."

This statement is correct. Elevating the affected area can help reduce swelling and minimize bleeding by promoting venous return. Elevating the limb above the level of the heart can aid in controlling bleeding and is a recommended intervention.

B. "I will apply warm compresses over the site."

This statement is incorrect. Applying warm compresses is generally not recommended for controlling bleeding in hemophilia. Heat can increase blood flow to the area, potentially exacerbating bleeding. Cold compresses or ice packs are typically recommended to help constrict blood vessels and reduce bleeding.

C. "I will have my child rest."

This statement is correct. Resting is an essential component of managing bleeding episodes in children with hemophilia. Physical activity and exertion can increase the risk of injury and bleeding, so it's important for children with hemophilia to avoid strenuous activities during bleeding episodes.

D. "I will promptly mobilize the involved area to relieve pain & decrease bleeding."

Immobilizing the affected area can help control bleeding and reduce pain by minimizing movement. This is also an appropriate response.

Correct Answer is ["5.4"]

Explanation

Convert the child's weight from pounds (lb) to kilograms (kg):

20 lb × (1 kg / 2.20462 lb) ≈ 9.07 kg

Calculate the total daily dose of cefazolin:

Total daily dose = 30 mg/kg/day × 9.07 kg = 272.1 mg/day

Divide the total daily dose into two equal doses:

Each dose = 272.1 mg / 2 ≈ 136.05 mg

Determine the dose per ml using the available oral suspension concentration:

125 mg/5 ml = 25 mg/ml

Calculate the volume of oral suspension needed for each dose:

Volume per dose = Dose per dose / Concentration per ml

≈ 136.05 mg / 25 mg/ml

≈ 5.44 ml

So, the child should receive approximately 5.44 ml per dose of cefazolin oral suspension.

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A nurse is caring for a 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about controlling a bleeding episode with a parent of a child who has hemophilia. Which of the following statements by the parent indicates a need for further teaching?

Correct Answer is B

Explanation

Primary care provider orders cefazolin (Kefrol) 30 mg/kg in two divided doses per day for a child with pneumonia. Child weighs 20 lb. If the available oral suspension is 125 mg/5ml how many mls per dose should the child receive?

Correct Answer is ["5.4"]

Explanation

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