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
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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Related Questions
Correct Answer is D
Explanation
A. CPR is not typically necessary unless the child stops breathing or the heart stops during the seizure, which is rare.
B. Restraining a child during a seizure can cause injury. The focus should be on safety and protection, not restraint.
C. Lorazepam may be given if the seizure lasts too long, but ensuring safety is the priority action.
D. The nurse’s priority during a seizure is to ensure the child’s safety by removing hazardous items from the area and ensuring the child does not get injured.
Correct Answer is B
Explanation
A. The temperature of the cast is important to check for heat retention but is not the first priority for infection control.
B. Assessing skin integrity around the cast is a priority to detect signs of infection, irritation, or pressure sores.
C. Range of motion is important but should be assessed once the skin and safety around the cast are ensured.
D. While pain level is important, ensuring skin integrity is a higher priority for preventing complications such as infection.
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