Free NCLEX-RN Exam Braindumps (page: 139)

Page 139 of 431

A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

  1. Head of bed elevated 30 degrees on nonoperative side
  2. Head of bed elevated 30 degrees on operative side
  3. Bed flat on operative side
  4. Bed flat on nonoperative side

Answer(s): D

Explanation:

(A) Elevation of head on nonoperative side would be the position for the late postoperative period. (B) Positioning on operative side puts pressure on the suture lines and on the shunt valve. Elevation of head in immediate postoperative period may cause rapid reduction of cerebrospinal fluid. (C) Placement on operative side puts pressure on the suture lines and shunt valve. (D) Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.



A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

  1. Head of bed elevated 30 degrees on nonoperative side
  2. Head of bed elevated 30 degrees on operative side
  3. Bed flat on operative side
  4. Bed flat on nonoperative side

Answer(s): D

Explanation:

(A) Elevation of head on nonoperative side would be the position for the late postoperative period. (B) Positioning on operative side puts pressure on the suture lines and on the shunt valve. Elevation of head in immediate postoperative period may cause rapid reduction of cerebrospinal fluid. (C) Placement on operative side puts pressure on the suture lines and shunt valve. (D) Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.



A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:

  1. Gavage tube
  2. Nipple and bottle
  3. A straw and cup
  4. Syringe

Answer(s): D

Explanation:

(A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3-month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This
minimizes the amount of sucking needed.



A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:

  1. Gavage tube
  2. Nipple and bottle
  3. A straw and cup
  4. Syringe

Answer(s): D

Explanation:

(A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3-month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This
minimizes the amount of sucking needed.



Page 139 of 431



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