Question

The nurse preceptor is working with the newly licensed registered nurse in caring for a patient with a newly placed ventricular shunt. What statement made by the new nurse requires immediate intervention by the preceptor?

a) "I need to wear sterile gloves whenever I palpate the incision site."
b) "I should be concerned if my patient begins to vomit and has a headache."
c) "I need to compare my assessment findings now with preoperative assessments."
d) "I need to tell the unlicensed assistive personnel (UAP) to get the patient up quickly to prevent headaches."

Answer 1

The new nurse's idea to have the UAP get the patient up quickly to prevent headaches (option d) after ventricular shunt placement requires immediate correction by the preceptor to avoid complications like increased intracranial pressure or shunt misplacement.

Step-by-step explanation:

The statement made by the new nurse that requires immediate intervention by the preceptor is: "I need to tell the unlicensed assistive personnel (UAP) to get the patient up quickly to prevent headaches." This statement is incorrect and potentially hazardous following the placement of a ventricular shunt. Rapid position changes can lead to increased intracranial pressure and cause complications like hemorrhage or shunt misplacement.

The correct actions after such a surgery include maintaining proper head elevation, slow and careful movement to prevent rapid intracranial pressure changes, and meticulous observation for signs of shunt malfunction or infection. A headache and vomiting can be indicative of increased intracranial pressure or shunt malfunction, which is a serious concern that should be addressed immediately. Comparison of postoperative assessment findings with preoperative assessments is a standard of care to monitor for any changes in the patient's condition.