The nurse is very busy and running late with administering medications and asks the practical nurse (PN) to administer a medication already drawn up in an unlabeled syringe. How should the PN respond?

A. Measure head circumference daily: Measuring the head circumference helps detect changes in intracranial pressure and assess shunt function. A sudden increase may indicate shunt malfunction or obstruction, making daily monitoring an essential part of postoperative care.

B. Place in Trendelenburg position: The Trendelenburg position increases intracranial pressure and should be avoided in infants with a ventriculoperitoneal shunt. The preferred position is supine with the head slightly elevated to promote cerebrospinal fluid drainage.

C. Irrigate shunt and pump valve every 12 hours: Shunt irrigation is contraindicated because it introduces a risk of infection and mechanical damage to the shunt system. Only trained neurosurgical personnel should manipulate or assess shunt function under sterile conditions.

D. Document strict intake and output: Accurate monitoring of intake and output helps assess fluid balance and detect complications such as dehydration or fluid overload, which can affect cerebrospinal fluid dynamics and overall recovery.

E. Monitor body temperature every 4 hours: Regular temperature monitoring is vital because fever may signal shunt infection or meningitis, both serious postoperative complications. Early detection of temperature changes allows for prompt medical intervention.

A. Auscultate all lung fields: In left-sided heart failure, fluid backs up into the lungs, leading to pulmonary congestion and crackles. Assessing all lung fields allows the PN to detect early signs of worsening HF, such as pulmonary edema, which can rapidly become life-threatening.

B. Measure urinary output: Monitoring urine output is important for assessing kidney perfusion and fluid balance, but pulmonary congestion poses a more immediate risk in left-sided HF than changes in urine output.

C. Inspect for sacral edema: Sacral edema is more commonly associated with right-sided heart failure. While peripheral edema should be monitored, it is less critical than evaluating for pulmonary complications in left-sided HF.

D. Check mental acuity: Altered mental status can occur if hypoxia develops from severe pulmonary congestion, but initial assessment focuses on lung function to prevent acute respiratory compromise.