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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Instruct the client to cough. Coughing is generally encouraged after chest physiotherapy to help expel loosened secretions, but it is not the first action. The bronchodilator should be administered first to maximize the effectiveness of the chest physiotherapy.
B. Perform vibration while the client exhales slowly through the nose. Vibration is a component of chest physiotherapy used to help loosen secretions during exhalation, but it is performed after the bronchodilator is administered and once the client is positioned properly.
C. Percuss the upper posterior chest.Percussion helps to mobilize secretions but is typically done after the bronchodilator has been administered to allow for more effective airway clearance.
D. Administer albuterol by nebulizer.Administering albuterol first dilates the airways, making it easier to mobilize and clear secretions during percussion, vibration, and postural drainage.
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