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. You seem overwhelmed, I'll contact the chaplain to come and talk with you about the options: While offering chaplain support is valuable, it's essential to engage in a conversation with the parents first to understand their needs and concerns.
B. I find it helpful to investigate the options. I will get you a pamphlet about end-of-life care: Providing information is valuable, but in this case, the parents are expressing their emotional distress, and they may need a more empathetic and personalized approach.
C. It's hard to say what the best decision is, but I know the end-of-life team provides wonderful care: While reassuring, this response doesn't actively engage with the parents or explore their feelings and beliefs, which are crucial for making this challenging decision.
D. These decisions are challenging. Tell me about your beliefs and understanding about end-of-life.
This response acknowledges the parents' difficulty with the decision and opens the door for a deeper conversation. It allows the nurse to understand the parents' perspectives, values, and concerns, which is crucial in providing holistic and patient-centered care. This information will help the nurse support the family and guide them through the decision-making process, addressing their specific needs and preferences.
Correct Answer is B
Explanation
A. Prevent ear infections: While individuals with cleft palates are at increased risk of ear infections, the primary immediate goal is not ear infection prevention.
B. Establish feeding and sucking.
Clefts of the soft palate can make it challenging for the baby to create a proper seal for sucking and feeding. Ensuring that the baby can feed effectively is a crucial initial goal. This may involve special nipples, bottles, or breastfeeding techniques to help the baby get proper nutrition.
While eventually repairing the cleft palate is an important part of the overall care plan, the immediate goal is to ensure that the baby can feed and gain weight properly.
C. Repair the cleft palate: Surgical repair of the cleft palate is typically done when the child is older. The immediate concern for a newborn is feeding.
D. Help the mother bond with the baby: This is an important aspect of care but not the primary goal for the baby's health and well-being. Bonding can occur while addressing the baby's feeding needs.
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