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
The Correct Answer is A
Rationale:
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 D
Explanation
Rationale:
A. Bradycardia is not typically associated with pulmonary edema; instead, tachycardia is more common as the body tries to compensate for decreased oxygenation.
B. Wheezing may occur in certain respiratory conditions but is not a classic finding in pulmonary edema; instead, crackles or rales are more expected due to fluid accumulation.
C. Pale, dry skin is not characteristic of pulmonary edema; the client may present with cyanosis or clammy skin due to hypoxia.
D. Pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the alveoli and is often associated with acute heart failure.
Correct Answer is C
Explanation
Rationale:
A. Comparing the nurse's skills to coworkers may not provide an accurate evaluation as it can vary based on individual roles and responsibilities.
B. While client satisfaction reports can reflect overall performance, they may not specifically address time management skills.
C. Maintaining regular notes about the nurse's time management skills allows for ongoing assessment and provides concrete examples during the appraisal, making it the most effective method.
D. Asking another staff nurse for evaluation can introduce bias and may not provide a comprehensive view of the nurse's time management skills.