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. Determine the means by which residents will be evacuated. - This task requires critical decision-making and understanding of evacuation protocols, which is within the scope of the practical nurse's responsibilities.
B. Close all fire doors and the doors to all the residents' rooms. - While important for containment, this can be executed by UAP following established protocols.
C. Assist any wandering residents back to their rooms. - UAP can assist in guiding residents back to their rooms safely.
D. Offer comfort and reassurance to distraught residents. - Both PN and UAP can offer comfort and reassurance to residents during such situations.

A. Checks the medical record for the correct signed consent form prior to the examination. B. Explains the examination and ask the client to sign the consent form. C. Explains to a family member and obtain their signature on the consent form. D. Asks if the client understands the exam and why the consent form must be signed. E. Asks if the client understands the exam and why the consent form must be signed.

Correct Answer is A

Explanation

A. Checks the medical record for the correct signed consent form prior to the examination. - Verifying that the correct consent form is signed and present in the medical record before the invasive examination is crucial to ensure the procedure is performed with proper authorization.
B. Explains the examination and asks the client to sign the consent form. - While it's important to explain the examination, obtaining consent typically involves the healthcare provider or a designated professional.
C. Explains to a family member and obtains their signature on the consent form. - Consent generally needs to be obtained directly from the client or their legally authorized representative, not just a family member.
D. Asks if the client understands the exam and why the consent form must be signed. - While educating the client about the procedure and the purpose of consent is important, it doesn't cover the formal process of obtaining and verifying the consent form.

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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

When a small fire breaks out in the kitchen of a long-term care facility, which task should be performed by the practical nurse (PN) rather than the unlicense assistive personnel (UAP)?

Correct Answer is A

Explanation

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

Correct Answer is A

Explanation

When a small fire breaks out in the kitchen of a long-term care facility, which task should be performed by the practical nurse (PN) rather than the unlicensed assistive personnel (UAP)?

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