A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?

Irritability when being held

Heart rate 122/min

Hypoactive bowel sounds

Urine specific gravity 1.018

Answer and Explanation

The Correct Answer is A

A. Irritability when being held may indicate increased intracranial pressure or complications related to the VP shunt placement and should be reported to the provider.

B. A heart rate of 122/min is within the normal range for an infant and does not require reporting.

C. Hypoactive bowel sounds may occur postoperatively, especially if the infant has not been fed or has been under anesthesia, and is not an immediate concern.

D. A urine specific gravity of 1.018 is within normal limits for infants and does not indicate a need for reporting.

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Correct Answer is C

Explanation

A. Concerns about participation in team sports may indicate a desire for improved lung function but do not directly necessitate the use of a high-frequency chest compression vest.

B. Discomfort during nebulizer treatments may warrant alternative therapies, but it is not a direct indication for a high-frequency chest compression vest.

C. A small amount of mucus after percussion therapy suggests inadequate airway clearance, which may prompt the need for more effective techniques, such as the high-frequency chest compression vest, to facilitate mucus clearance and improve lung function.

D. A fever indicates a potential infection and requires further assessment but does not directly suggest the need for a high-frequency chest compression vest.

A. Assess a client who has hypomania for exhaustion B. Accompany a client who has depression to occupational therapy C. Check the position of a client in soft wrist restraints D. Sit with a client who has alcohol use disorder and whose last drink was five days ago E. Set limits with a client who has mania

Correct Answer is D

Explanation

Assessing a client requires clinical judgment and should not be delegated to an AP.

B. Accompanying a client to occupational therapy is a task that can be safely assigned to an AP as it does not require clinical judgment.

C. Checking the position of a client in soft wrist restraints is a routine task that can be assigned to an AP as long as the AP has been trained in restraint protocols.

D. Sitting with a client who has alcohol use disorder (5 days after their last drink) is a task that an AP can perform, especially if the client does not require close monitoring for medical complications such as delirium tremens.

E. Setting limits with a client requires therapeutic communication skills and clinical judgment, so this should not be delegated to an AP.

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A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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