A new nurse is caring for a child who had a ventriculoperitoneal shunt placed 2 days ago for hydrocephalus. Which action by the new nurse causes the experienced nurse to intervene?
A.
Administers IV antibiotics
B.
Asks for medication to treat nausea
C.
Palpates the shunt tract with assessments
D.
Raises the head of the bed to 30 °
ANS: B
Peritonitis is a complication of this procedure and manifestations of this include rebound tenderness, abdominal muscle rigidity, nausea, and vomiting. The new nurse should conduct a more thorough abdominal assessment instead of asking for anti-nausea medication. The other actions are appropriate and do not require the experienced nurse to intervene.
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