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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. While assessing pain level is important for comfort management, it is not the highest priority in the immediate postpartum period.

B. The amount of vaginal bleeding is critical to assess during the fourth stage of labor to identify potential postpartum hemorrhage, especially with oxytocin administration.

C. Although urinary output is important to monitor for bladder distension, it does not take precedence over bleeding assessment.

D. Fundal height assessment is necessary to ensure the uterus is contracting effectively, but again, it is secondary to monitoring for bleeding.

A. The client will have a visit by a home health nurse tomorrow. B. The client needs assistance when transferring from the bed to a wheelchair. C. The client's partner will bring clothes for the client to change into prior to discharge. D. The client often needs encouragement to engage in personal hygiene activities.

Correct Answer is B

Explanation

While a home health nurse visit is important, it is not an immediate safety concern for the client's discharge.

B. The need for assistance when transferring is critical information as it directly impacts the client's safety during discharge; the oncoming nurse must ensure proper support is arranged.

C. The fact that the client's partner will bring clothes is relevant but does not affect the immediate care of the client.

D. Encouragement for personal hygiene is important but is not as urgent as ensuring the client can safely transfer without risk of falls or injury.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?

Correct Answer is B

Explanation

A night shift nurse is giving change-of-shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse?

Correct Answer is B

Explanation

A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take?

A nurse is assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make?

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm³ (2500 to 8000/mm³). Which of the following interventions should the nurse include in the plan?

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to improve communication?

A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills?

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?