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 D
Explanation
A. Explaining to the teenager that he is lucky to receive good care does not address his emotional and social needs adequately and may minimize his feelings.
B. Arranging for a video conference with his teacher and ensuring schoolwork is available is important but does not address his desire to be with friends or his emotional needs.
C. Asking the child-life specialist to help find activities to distract the teenager can be helpful for providing emotional support but may not address his concerns about being with friends and feeling frustrated.
D. Arrange a multi-disciplinary team meeting, including the teenager and his family, to discuss the situation and set goals together.
In this challenging situation, it's important to involve the patient and their family in decision-making and goal-setting. Advanced osteosarcoma with metastasis to the lungs is a serious and potentially terminal illness. The teenager's feelings and wishes should be respected and taken into consideration. A multi-disciplinary team meeting allows for open communication, including the patient, family, healthcare providers, and specialists, to discuss the situation, the patient's preferences, and the overall care plan.
Correct Answer is C
Explanation
A. Neutropenic Precautions: Neutropenia refers to a low neutrophil count, a type of white blood cell responsible for fighting infections. While children with leukemia are at risk for neutropenia due to the disease and its treatment, the primary concern in this scenario is the critically low platelet count and the risk of bleeding. Neutropenic precautions focus on preventing infections.
B. Droplet Precautions: Droplet precautions are used when dealing with respiratory infections that are transmitted through respiratory droplets, such as coughing or sneezing. This is not the primary concern for a child with leukemia and a low platelet count, as the main risk is bleeding due to the low platelet count.
C. Bleeding Precautions: Leukemia, especially in a child with a critically low platelet count, puts the child at a high risk of bleeding. Platelets are essential for blood clotting, and when they are severely decreased, even minor injuries can lead to excessive bleeding. The nurse should take precautions to minimize the risk of bleeding. This includes avoiding invasive procedures, using a soft toothbrush, and ensuring that the child does not participate in activities that could result in injury.
D. Contact Precautions: Contact precautions are used to prevent the transmission of infectious diseases through direct contact. While a child with leukemia may have a weakened immune system and be at risk of infections, the primary concern in this case is the critically low platelet count and the risk of bleeding. Contact precautions are more relevant in cases of contagious diseases where physical contact could transmit the infection.
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