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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Option A, "Fatigue," is a symptom of anemia but is not a long-term complication associated with Thalassemia major.
Option B, "Deferoxamine usage," is a treatment to manage iron overload and not a complication associated with Thalassemia major.
Option C, "Immunosuppressive therapy," is not typically used to manage Thalassemia major and is not a long-term complication but rather a potential treatment for certain cases of thalassemia.
Option D. Hemochromatosis/Hemosiderosis
Thalassemia major is a genetic disorder that results in the body's inability to produce enough hemoglobin, leading to severe anemia.
To manage this condition, frequent blood transfusions are required, which can lead to iron overload in the body. Excess iron gets deposited in various organs and tissues, causing damage.
Hemochromatosis or hemosiderosis is a condition characterized by the accumulation of iron in organs like the liver, heart, and endocrine glands, which can result from repeated blood transfusions.
The complications associated with iron overload include liver damage, heart problems, diabetes, and more. Treatment with iron chelating agents like deferoxamine is often necessary to remove excess iron from the body.
Correct Answer is B
Explanation
A. Positive Western blot test: A positive Western blot test confirms HIV infection but doesn't provide information about the current immune status or progression of the disease.
B. CD4-T-cell count 180 cells/mm³.
The CD4-T-cell count is a crucial indicator of a person's immune system function, and it's a primary marker used to monitor the progression of HIV infection. A CD4 count of 180 cells/mm³ is significantly below the normal range (which is typically higher), indicating immunosuppression and an increased risk of opportunistic infections. Maintaining and improving immune function is a top priority in the care of clients with HIV.
C. Platelets 150,000/mm³: Platelet counts are important, but they are not the primary indicator for assessing the progression of HIV.
D. WBC 5.000/mm³: The white blood cell count (WBC) is important for assessing overall immune function, but it doesn't provide the same specific information about the immune system status as the CD4-T-cell count.
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