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
Explanation
A. Missing pulse. - This term implies the complete absence of a pulse, which might not be the case here; the pulse is present but disappears with light pressure.
B. Thready pulse volume. - A thready pulse refers to a weak pulse that is easily obliterated with light pressure. This accurately describes the finding observed by the PN.
C. Light pressure applied to pulse. - This description simply explains the technique used to assess the pulse and does not adequately capture the quality of the pulse.
D. Pulse skips beats. - This term refers to an irregularity in the pulse rhythm, not to the disappearance with light pressure.
Correct Answer is B
Explanation
This statement shows awareness but doesn't necessarily indicate acceptance of the prognosis. B. Acceptance is often linked with finding emotional support, and this statement implies the client has found solace and support from faith and family, reflecting a level of acceptance. C. This statement suggests a disbelief or denial of the diagnosis, which is not indicative of acceptance.
D. This statement reflects resistance and denial rather than acceptance of the prognosis. Acceptance usually involves acknowledgment and finding ways to cope positively, which is not shown in this statement.
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