A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt?

Movement of all extremities.

Negative Brudzinski sign.

Incisional pain.

Bulging fontanel.

Answer and Explanation

The Correct Answer is D

Choice A reason: Movement of all extremities is expected and does not indicate a shunt malfunction.
Choice B reason: A negative Brudzinski sign is a normal finding and does not suggest a shunt malfunction.
Choice C reason: While incisional pain is common after surgery, it is not a specific indicator of shunt malfunction.
Choice D reason: This is the correct choice. A bulging fontanel can indicate increased intracranial pressure, which may suggest a shunt malfunction.

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Correct Answer is A

Explanation

Choice A reason: This is the correct choice. A respiratory rate of 48 is high for a 3-year-old, indicating that the croup is affecting his breathing.
Choice B reason: This choice is incorrect. A heart rate of 90 is within the normal range for a 3-year-old.
Choice C reason: This choice is incorrect. A blood pressure of 100/52 is within the normal range for a 3-year-old.
Choice D reason: This choice is incorrect. A temperature of 98.8°F (37.1°C) is within the normal range for a 3-year-old.

A. Give the client six ounces of non-diet carbonated soda and instruct the client to drink it entirely. B. Document the glucose reading in the electronic medical record as the only action needed. C. Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis. D. Prepare the prescribed dose of rapid-acting insulin from the sliding scale instructions.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice. A blood glucose level of 56 mg/dL indicates hypoglycemia, and the immediate priority is to raise the blood sugar level. Non-diet carbonated soda can provide a quick source of sugar.
Choice B reason: Documenting the reading is important but does not address the immediate need to correct the low blood sugar.
Choice C reason: While confirming the reading with a laboratory test is a good practice, it is not the first action to take when dealing with hypoglycemia.
Choice D reason: Administering insulin would be contraindicated as it would lower the blood sugar even further.

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A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 3-year-old admitted to the hospital with croup has the following vital signs: heart rate 90, respiratory rate 48, blood pressure 100/52, and temperature 98.8°F (37.1°C). The parents ask the nurse if these vital signs are normal. The nurse's best response is:

Correct Answer is A

Explanation

The nurse obtains a fingerstick blood glucose level using bedside lancet/glucose meter equipment from a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). At this time, which intervention should the nurse implement first?

Correct Answer is A

Explanation

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