A nurse is caring for a child who has undergone a Ventriculoperitoneal (VP) shunt placement procedure. The nurse is aware of the need for careful prioritization of care. Which of the following actions should the nurse prioritize for this child?

Administering pain medication as needed

Providing a low-sodium diet to prevent fluid overload

Encouraging the child to ambulate as soon as possible

Assessing vital signs every 4 hours

Answer and Explanation

The Correct Answer is D

A.   While pain management is important, the priority is assessing for complications that could arise after the procedure.
B.   Discharge teaching is important, but the priority immediately after the procedure is monitoring for complications.
C.   While hydration is important, it is not the immediate priority following VP shunt placement, where the focus should be on assessing for signs of complications.
D.   Regular monitoring of vital signs is crucial to detect complications such as shunt malfunction, infection, or increased intracranial pressure.

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Correct Answer is D

Explanation

A. Bradycardia is not a typical finding with PDA.
B. Cyanosis is more likely to occur with severe heart defects or in situations where there is a right-to-left shunt, which is not typical of PDA.
C. Weak pulses are not typical of PDA; instead, bounding pulses may be present.
D. A widened pulse pressure (a significant difference between systolic and diastolic blood pressure) is commonly seen in large PDA due to the continuous blood flow from the aorta to the pulmonary arteries.

A. Dress the child in woolen clothes during cold months. B. Encourage the parent to bathe the child daily with hot water and mild soap to keep the skin clean. C. Instruct the parent to dress the child in loose-fitting cotton clothing to help prevent irritation. D. Suggest to the parent to avoid using any moisturizers on the child's skin to prevent further irritation.

Correct Answer is C

Explanation

A. Woolen clothes may irritate the skin and should be avoided by children with eczema.
B. Hot water and frequent baths can dry out and irritate the skin, worsening eczema. Lukewarm water is recommended.
C. Loose cotton clothing helps to minimize irritation and sweating, which can worsen eczema symptoms.
D. Moisturizers are essential for managing eczema and preventing skin dryness. They should be used regularly.

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A nurse is caring for a child who has undergone a Ventriculoperitoneal (VP) shunt placement procedure. The nurse is aware of the need for careful prioritization of care. Which of the following actions should the nurse prioritize for this child?

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