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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You can give your child acetaminophen (Tylenol) every 4-6 hours as needed for pain."
Option A is the most appropriate response because it addresses pain management, which is a common symptom in cases of tonsillitis. Acetaminophen can be used to provide relief from pain and fever, which are often associated with viral tonsillitis. However, it's important for the parent to follow the dosing instructions on the medication label and consult with their healthcare provider if they have any concerns or if the child's condition worsens.
Option B ("You will need to schedule a follow-up appointment in 2 weeks") is also not the best initial response, as it doesn't address immediate care at home for the child's comfort and pain relief.
Option C ("You will need to give your child a prescribed antibiotic for 10 days") is not the correct approach, as antibiotics do not treat viral illnesses. Viral tonsillitis is usually caused by a viral infection, and antibiotics are not effective for viral infections.
Option D ("You can place warm towels around your child's neck for comfort") can provide some comfort but is not the primary treatment for viral tonsillitis. It may help alleviate discomfort, but pain relief with acetaminophen is typically more effective.
Correct Answer is C
Explanation
A. Demonstrating independent dressing is usually not expected at 18 months. Toddlers are still developing fine motor skills and may need assistance with dressing.
B. Using a vocabulary of 300 words is advanced for an 18-month-old. At this age, most children have a more limited vocabulary, typically around 50 words or so.
C. Jump with both feet.
At 18 months of age, children are usually developing their motor skills, including gross motor skills like walking, running, and jumping. Jumping with both feet is an age-appropriate milestone for a toddler of this age.
D. Walking upstairs with one hand held is typically not expected at 18 months. This is a skill that develops later as toddlers gain more confidence in their mobility and coordination.
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