A 2-day-old infant with hydrocephalus returns from surgery following placement of a ventriculoperitoneal shunt. Which nursing intervention(s) should the practical nurse (PN) implement during postoperative care? (Select all that apply.)

Measure head circumference dally.

Document strict intake and output.

Irrigate shunt and pump valve every 12-hours.

Monitor body temperature every 4-hours.

Answer and Explanation

Correct Answer : A,B,D

A.   Measure head circumference daily. - Monitoring head circumference is crucial to detect changes that might indicate increased intracranial pressure after the shunt placement.
B.   Document strict intake and output. - Monitoring fluid intake and output helps assess the infant's hydration status and shunt functionality.
C.   Irrigate shunt and pump valve every 12-hours. - Shunt irrigation should be performed by specialized healthcare professionals, not typically by a practical nurse.
D.   Monitor body temperature every 4 hours. - Postoperative monitoring includes assessing for signs of infection or systemic changes, which might be indicated by changes in body temperature.
E.   Place in Trendelenburg position. - The Trendelenburg position is not typically recommended post-ventriculoperitoneal shunt placement and should be avoided unless specifically prescribed by the healthcare provider.

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Correct Answer is A

Explanation

A. Keep the hearing aid out of direct sunlight. - This instruction is accurate as exposure to direct sunlight can potentially damage the hearing aid components, such as the battery or delicate electronic parts.
B. Wear the hearing aid while sleeping. - It's generally advised to remove hearing aids before sleeping to allow the ears to rest and prevent potential damage to the device.
C. Clean the hearing aid with baby oil. - Baby oil can damage the hearing aid and should not be used for cleaning. Specific cleaning solutions recommended by the manufacturer should be used.
D. Leave the hearing aid in place while showering. - Water exposure can damage the hearing aid, so it's advisable to remove it before showering or bathing.

A. A Irrigate an indwelling urinary catheter for a client with bladder suspension. B. Empty bedside drainage unit for a client with indwelling urinary catheter. C. Transport a urine culture sample to the laboratory. D. Obtain a post-voided residual (PVR) volume.

Correct Answer is ["B","C","D"]

Explanation

A. Irrigate an indwelling urinary catheter for a client with bladder suspension. - This procedure requires specialized skills and should be performed by a licensed nurse.
B. Empty bedside drainage unit for a client with an indwelling urinary catheter. - UAP can safely perform this task by following established protocols to maintain catheter hygiene.
C. Transport a urine culture sample to the laboratory. - This task involves safely transporting a specimen and does not require specialized medical knowledge.
D. Obtain a post-voided residual (PVR) volume. - This task can be performed by UAP under supervision or with appropriate training, using a bladder scanner or assisting the client to measure remaining urine.
E. Teach the client with fluid restrictions how to measure urine output. - Teaching tasks generally fall under the responsibility of licensed nursing staff and may require specific medical knowledge.

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A 2-day-old infant with hydrocephalus returns from surgery following placement of a ventriculoperitoneal shunt. Which nursing intervention(s) should the practical nurse (PN) implement during postoperative care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client is fitted with a hearing aid and instructions are provided for its use. Which instruction is accurate and should be reinforced by the practical nurse (PN)?

Correct Answer is A

Explanation

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long term care facility consistently records subnormal temperatures when using a tympanic thermometer. Which action should the PN take first?

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The practical nurse (PN) is assisting with the preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?