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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
The picture shows that the newly hired PN is about to make a serious error by adding the medication directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the medication. The PN should demonstrate how to administer medication via a feeding tube correctly, which involves stopping the feeding, flushing the tube with water, instilling the medication, flushing again, and resuming the feeding.
The other options are not correct because:
B. Confirming that the medication is only administered once daily is not relevant or helpful, as it does not address the error or teach the correct technique of administering medication via a feeding tube.
C. Determining if the medication is compatible with the solution is not necessary or appropriate, as the medication should not be mixed with the solution in the first place, but given separately through the feeding tube.
D. Offering to assist in calculating the rate of flow for the mixture is not relevant or helpful, as there should be no mixture of medication and solution in the feeding bag, but separate administration of each through the feeding tube.
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