A nurse is caring for a child who has undergone a Ventriculoperitoneal (VP) shunt placement procedure. The nurse is aware of the need for careful prioritization of care. Which of the following actions should the nurse prioritize for this child?

Administering pain medication as needed

Providing a low-sodium diet to prevent fluid overload

Encouraging the child to ambulate as soon as possible

Assessing vital signs every 4 hours

Answer and Explanation

The Correct Answer is D

A.   While pain management is important, the priority is assessing for complications that could arise after the procedure.
B.   Discharge teaching is important, but the priority immediately after the procedure is monitoring for complications.
C.   While hydration is important, it is not the immediate priority following VP shunt placement, where the focus should be on assessing for signs of complications.
D.   Regular monitoring of vital signs is crucial to detect complications such as shunt malfunction, infection, or increased intracranial pressure.

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Correct Answer is ["A","C","D"]

Explanation

A. Right atrial enlargement occurs due to the increased blood flow from left to right shunting, which can cause volume overload in the right atrium.
B. Left atrial enlargement is typically seen in conditions that cause increased left atrial pressure, such as mitral valve disease or left-sided heart failure, not in ASD.
C. Shortness of breath is a common symptom due to increased blood flow to the lungs, which can lead to pulmonary congestion.
D. Pulmonary hypertension may develop over time due to increased blood flow and pressure in the pulmonary circulation from the left-to-right shunting of blood.
E. Pulmonary hypotension is not associated with ASD. The condition typically leads to increased pressure in the pulmonary arteries, not decreased pressure

A. Administering a bolus (250 ml) of Normal saline intravenous fluid B. Administering oxygen C. Administering pain medication D. Administering antipyretics

Correct Answer is C

Explanation

A. While hydration is important to help with blood flow, pain management takes precedence during an SCD crisis.
B. Oxygen may be necessary in certain cases but is not the priority in the acute pain crisis, where pain control is the primary concern.
C. Pain management is the priority in sickle cell disease (SCD) crisis, as it helps alleviate the intense pain associated with vaso-occlusive events.
D. Antipyretics are not the priority unless the child has a fever. Pain relief is more urgent during a crisis.

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A nurse is caring for a child who has undergone a Ventriculoperitoneal (VP) shunt placement procedure. The nurse is aware of the need for careful prioritization of care. Which of the following actions should the nurse prioritize for this child?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a 3-year-old client who has been diagnosed with an Atrial Septal Defect (ASD). Which of the following findings should the nurse expect? (Select All That Apply)

Correct Answer is ["A","C","D"]

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The nurse provides care to a client who is admitted for a sickle cell disease (SCD) crisis. Which of the following is the priority prescription for the nurse to Implement when providing patient care?

Correct Answer is C

Explanation

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