A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

Urine output of 50 mL in 2 hr

Lethargy

Respiratory rate 24/min

Absent Babinski reflex

Answer and Explanation

The Correct Answer is B

A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.

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Correct Answer is ["A","B","C","F","G","H"]

Explanation

A. Maintain NPO status. The child is at risk for surgery, and maintaining NPO status reduces the risk of aspiration.
B. Administer an antipyretic. Reducing fever can improve comfort and decrease metabolic demand.
C. Initiate an infusion of IV fluids. IV fluids prevent dehydration, especially since the child has had poor oral intake and diarrhea.
D. Administer a cleansing enema. An enema is contraindicated as it may worsen abdominal inflammation or cause perforation.
E. Prepare child and parents for ostomy placement. While surgery may be needed, an ostomy is not always required for appendicitis.
F. Educate child and parents about plan of care. Providing education helps reduce anxiety and ensures understanding of the interventions.
G. Administer an analgesic. Pain management is essential for comfort and reduces physiologic stress.
H. Administer antibiotics. Antibiotics are started preoperatively to manage infection or prevent complications if perforation is suspected.

A. Protective environment B. Airborne C. Contact D. Droplet

Correct Answer is D

Explanation

A. Protective environment: This is for immunocompromised clients, not infectious diseases like pertussis.
B. Airborne: Airborne precautions are used for diseases like tuberculosis, measles, or varicella, which spread through smaller airborne particles.
C. Contact: Contact precautions are for diseases transmitted via direct contact, such as MRSA or C. difficile, and are not appropriate for pertussis.
D. Droplet. Pertussis is transmitted through respiratory droplets, so droplet precautions (e.g., wearing a surgical mask and maintaining distance) are essential to prevent the spread.

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A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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