An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Test the urine for protein

Reposition the infant frequently.

Assess blood pressure every 15 minutes

Provide a stimulating environment

Answer and Explanation

The Correct Answer is B

A. Test the urine for protein.
Explanation: Testing urine for protein is not a priority nursing intervention in the preoperative period for an infant with hydrocephalus. The focus is on preventing complications related to immobility and positioning.
B. Reposition the infant frequently.
Explanation:
Repositioning the infant frequently is a crucial intervention to prevent complications such as pressure ulcers (bedsores). Infants with hydrocephalus may be at an increased risk of skin breakdown due to prolonged immobility and pressure on specific areas. Repositioning helps distribute pressure, improves circulation, and reduces the risk of skin breakdown.
C. Assess blood pressure every 15 minutes.
Explanation: While monitoring blood pressure is important in certain situations, it is not typically the priority for an infant with hydrocephalus in the preoperative period. The focus is on preventing skin breakdown through repositioning.
D. Provide a stimulating environment.
Explanation: While providing a stimulating environment can be beneficial for infant development, it is not the priority in the preoperative period for an infant with hydrocephalus. The primary concern is addressing potential complications related to immobility, such as skin breakdown.

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Correct Answer is ["A","B","C","D"]

Explanation

A. The child needs to avoid exposure to other illnesses.
Explanation: Children with AIDS have compromised immune systems and are more susceptible to infections. Therefore, it is important to minimize exposure to other illnesses to reduce the risk of infections.
B. Frequent handwashing is important.
Explanation: Good hand hygiene helps prevent the spread of infections. Encouraging frequent handwashing is crucial in the care of a child with AIDS.
C. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).
Explanation: Using a bleach solution to clean up body fluid spills helps to disinfect and reduce the risk of transmission of infections. The recommended ratio is 10 parts water to 1 part bleach.
D. Monitor the child's weight.
Explanation: Monitoring the child's weight is important for assessing nutritional status and overall health. Weight loss may indicate underlying health issues that need attention.
E. The child's immunization schedule will need revision.
Explanation: Children with AIDS may have altered immune function, but the need for immunizations is still crucial. However, live vaccines may need to be avoided. The immunization schedule should be discussed and individualized with the healthcare provider.
F. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.
Explanation: While these symptoms may occur, they should not be dismissed without evaluation. Any changes in the child's health, including symptoms such as fever, malaise, fatigue, weight loss, vomiting, and diarrhea, should be reported to the healthcare provider for appropriate assessment and intervention.

Correct Answer is ["260"]

Explanation

To calculate the total fluid intake, add the volumes of each item consumed:

Juice: ½ cup

1 cup = 240 mL

½ cup = 240 mL / 2 = 120 mL

Gelatin: 3 oz

1 oz ≈ 30 mL

3 oz = 3 * 30 mL = 90 mL

Ice pop: 1 oz

1 oz ≈ 30 mL

1 oz = 30 mL

Ginger ale: 20 mL

Now, add these values:

120 mL (juice) + 90 mL (gelatin) + 30 mL (ice pop) + 20 mL (ginger ale) = 260 mL

Therefore, the nurse should record 260 mL as the child's fluid intake.

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An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

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Naxlex Comprehensive Predictor Exams

Which home care instructions would the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

Correct Answer is ["260"]

Explanation

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