Which action should the nurse take when providing postoperative nursing care to a child after insertion of ventriculoperitone (VP) shunt?
Check the urine for glucose and protein
Administer narcotics for pain control
Test cerebrospinal (CSP) fluid leakage for protein
Monitor for increased temperature
The Correct Answer is D
A. Checking urine for glucose and protein is not directly related to the care of a child with a VP shunt. The focus is on monitoring the child for signs of complications related to the shunt.
B. Administering narcotics for pain control may be indicated if the child is in pain, but it is not the primary action and should be determined based on the child's pain assessment.
C. Testing cerebrospinal (CSF) fluid leakage for protein is not typically a nursing responsibility in the immediate postoperative period. Leakage of CSF should be reported to the healthcare provider, and diagnostic tests would be conducted by medical staff as needed.
D. Monitor for increased temperature.
Monitoring for an increased temperature is essential because postoperative fever could be an early sign of infection or complications related to the VP shunt. Infection and shunt malfunction are potential risks in the postoperative period.
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Related Questions
Correct Answer is B
Explanation
A. Applying a warm soak to the knee: Heat application is generally not recommended during a vaso-occlusive crisis because it can worsen inflammation and pain.
B. Administering Acetaminophen.
Vaso-occlusive crises are a common complication of sickle cell disease, and they can lead to severe pain. Acetaminophen (Tylenol) is an appropriate choice for pain management in this situation. It is a non-steroidal anti-inflammatory drug (NSAID) that can help alleviate pain.Pain control is the priority in these situations.
C.Compression wraps can potentially exacerbate ischemia and increase the risk of complications.
D.Adequate hydration is essential during a crisis to prevent further sickling of red blood cells. Reducing fluids could exacerbate the condition
Correct Answer is C
Explanation
Option A (Place the infant in reverse Trendelenburg position) and option B (Place the infant in the knee to chest position) are not the immediate actions to address this situation. While these positions might be used in specific situations, assessing blood pressure is more appropriate in this context to evaluate for potential vascular issues.
Option C. Take the infant's blood pressure in all extremities.
In an infant with weaker femoral pulses compared to the brachial and radial pulses, there might be a concern about coarctation of the aorta (a narrowing of the aorta), which can affect blood flow to the lower extremities. To confirm this and assess for potential issues, taking blood pressure measurements in all four extremities is crucial. This comparison can help identify pressure differentials between the upper and lower extremities, which is a hallmark sign of coarctation of the aorta.
Option D (Notify the Physician) is generally a good step, but taking the blood pressure in all extremities should be done first to provide comprehensive information for the physician when discussing the infant's condition.
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