A charge nurse is assisting a newly licensed nurse with the preoperative assessment of a 2-year-old child who has a Wilms' tumor. Which of the following actions by the newly licensed nurse indicates an understanding of the needed care?
Measuring the child's abdominal circumference
Palpating the child's abdomen
Providing clear liquids up to 1 hr prior to surgery
Continuously monitoring the child's oxygen saturation
The Correct Answer is A
A. Measuring the child's abdominal circumference:
This is the correct action. Assessing the child's abdominal circumference is essential in monitoring the size of the Wilms' tumor and evaluating for any signs of abdominal distention or growth. Changes in abdominal circumference can provide valuable information about the progression of the tumor and any potential complications.
B. Palpating the child's abdomen:
Palpating the child's abdomen is an essential part of the physical examination to assess for the presence of a mass or any tenderness. However, in the case of a child with a known Wilms' tumor, palpation should be performed gently to avoid causing discomfort or disturbing the tumor.
C. Providing clear liquids up to 1 hr prior to surgery:
Providing clear liquids up to 1 hour prior to surgery is not appropriate for a child undergoing surgery, especially if anesthesia is involved. Preoperative fasting guidelines typically require clear liquids to be stopped a few hours before surgery to reduce the risk of aspiration.
D. Continuously monitoring the child's oxygen saturation:
Continuous monitoring of the child's oxygen saturation is an essential aspect of perioperative care, but it is not specific to the preoperative assessment for a child with Wilms' tumor. Oxygen saturation monitoring is typically performed throughout the perioperative period to ensure adequate oxygenation during surgery and recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dry mouth: Dry mouth is not a common adverse effect of cefazolin. It is more commonly associated with other medications, such as anticholinergic drugs. While dry mouth may be uncomfortable, it is not typically considered a serious adverse effect of cefazolin that requires immediate reporting.
B. Constipation: Constipation is also not a common adverse effect of cefazolin. It is more commonly associated with other medications, dietary factors, or underlying medical conditions. Similar to dry mouth, constipation is not typically considered a serious adverse effect of cefazolin that requires immediate reporting.
C. Back pain: Back pain is not a common adverse effect of cefazolin. While musculoskeletal adverse effects can occur with some antibiotics, back pain is not typically associated with cefazolin. However, if severe or persistent back pain occurs, it should be reported to the healthcare provider for evaluation.
D. Urticaria: Urticaria, also known as hives, is a potential adverse effect of cefazolin and other antibiotics. It is characterized by raised, itchy welts on the skin and can be a sign of an allergic reaction. Urticaria should be reported to the healthcare provider immediately, as it may indicate a serious allergic reaction requiring prompt medical attention.
Correct Answer is C
Explanation
A. Polyuria
Polyuria, or excessive urination, is not typically associated with intussusception. This symptom is more commonly seen in conditions affecting the kidneys or urinary tract.
B. Scaphoid abdomen
A scaphoid abdomen refers to a concave or hollowed appearance of the abdomen, which is not typically observed in intussusception. In intussusception, abdominal distension and tenderness are more common findings.
C. Gelatinous red stool
Gelatinous red stool, often described as "currant jelly" stool, is a classic manifestation of intussusception. It occurs due to the mixture of blood, mucus, and bowel contents.
D. Generalized edema
Generalized edema, or swelling throughout the body, is not a typical manifestation of intussusception. It is more commonly associated with conditions such as heart failure or kidney disease.
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