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 C

Explanation

A. Educate the infant's caregiver about the feeding: While important, education should occur after ensuring the prescription is correct.
B. Flush the feeding tube before the feeding: This ensures patency but should only be done after verifying the prescription.
C. Clarify the feeding prescription with the provider. Bolus feedings are typically contraindicated with nasojejunal tubes because the jejunum cannot handle large volumes at once. Continuous feedings are usually prescribed. The prescription should be clarified before proceeding.
D. Place a label on the feeding bag and tubing: Labeling is necessary for safety but is not the priority when the prescription may be inappropriate.

A. "I will cook foods that are low in fat and carbohydrates." B. "My child can chew their enzyme medication with meals." C. "I will give my child stool softeners for constipation." D. "My child will be excused from physical education class."

Correct Answer is C

Explanation

A. "I will cook foods that are low in fat and carbohydrates.": Children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B. "My child can chew their enzyme medication with meals.": Enzyme medications should not be chewed as they can irritate the oral mucosa; they should be swallowed whole or sprinkled on soft food.
C. "I will give my child stool softeners for constipation." Constipation is a common issue in cystic fibrosis due to thickened intestinal secretions. Stool softeners help prevent this complication.
D. "My child will be excused from physical education class.": Physical activity is encouraged for children with cystic fibrosis to improve lung function.

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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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