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NCLEX-RN

Category - Physiological

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A nurse is caring for a child who was just received in the unit after a ventriculoperitoneal shunt placement for the treatment of hydrocephalus. The nurse’s first priority is which of the following?

Assess the child’s surgical site.
Position the child on the side opposite the shunt.
Position the child on the same side of the shunt.
Administer oral pain medications.

Explanation

Answer: B - After surgery, the child should be positioned on the side opposite the shunt to prevent placing pressure on the shunt valve. Assessment of the surgical site is appropriate but correct positioning is the nurse’s priority at this time. Pain medications are administered through the IV and are not given by mouth.

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