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
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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Related Questions
Correct Answer is D
Explanation
A. Non-contact sports like swimming are generally safe for children with hemophilia as they carry a lower risk of injury.
B. Wearing helmets and protective gear is an important safety measure for children with hemophilia to prevent trauma.
C. While it is important to avoid excessive risk of injury, children with hemophilia can still participate in many activities with precautions.
D. NSAIDs should not be used in children with hemophilia as they can increase the risk of bleeding. Acetaminophen (Tylenol) is a safer option for pain relief.
Correct Answer is A
Explanation
A. Bacterial meningitis is highly contagious, and isolation precautions are necessary to prevent the spread of the infection to others. This should be the nurse's first action to protect both the child and others.
B. While antibiotics are crucial in treating bacterial meningitis, initiating isolation protocols is the first priority to prevent transmission to others.
C. A lumbar puncture is needed to confirm the diagnosis of meningitis, but isolation protocols should be established first to prevent spread.
D. Blood cultures are important for diagnosing bacterial meningitis but are secondary to ensuring proper isolation to prevent contagion.
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