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 B
Explanation
A. "Seal nonwashable items in a plastic bag for 2 days."
This instruction is incorrect. Items that cannot be laundered may be dry-cleaned or sealed in a plastic bag for two weeks
B. "Soak hair brushes in boiling water for 10 minutes."This is correct. According to CDC, combs and brushes should be soaked in hot water (at least 130 degrees fahrenheit) to help avoid re-infestation.
C. "Apply permethrin 1 percent cream rinse every day for 5 days."
This instruction is incorrect. Permethrin 1 percent cream rinse is a medication used to treat head lice infestations, but it is typically applied only once and then rinsed out after a specified period of time (usually 10 minutes). Repeated daily application for five days is not recommended and may lead to unnecessary exposure to the medication.
D. "After washing bed linens, place them in a dryer on a cool setting for 30 minutes."
This instruction is incorrect. To effectively kill lice and nits on bed linens, they should be washed in hot water (at least 130°F or 54°C) and then dried on a hot setting in the dryer. A cool setting may not be sufficient to kill lice and nits.
Correct Answer is A
Explanation
A. Preschoolers believe their illness is punishment for their misbehavior:This statement is true. Preschool-aged children often have a limited understanding of illness and may associate it with punishment. They might think that their illness is a consequence of something they did wrong. As a nurse, it’s essential to address these misconceptions and provide age-appropriate explanations to help them understand their condition better.
B. Preschoolers are interested in what happens to the body after death: Preschoolers may have curiosity about death and what happens afterward, but their understanding is typically limited. They may ask simple questions about death and may need age-appropriate explanations about the concept. Providing information in a sensitive and honest manner can help address their curiosity and alleviate fears.
C. Adolescents worry more about death than the physical changes that can occur as a result of the illness: Adolescents facing terminal illness may have complex emotions and concerns about both death and the physical changes associated with their illness. It's important to acknowledge and address both aspects of their experience, providing opportunities for adolescents to express their feelings and concerns in a supportive environment.
D. Toddlers personify death as being a type of monster: Toddlers often have limited understanding of death and may personify it in different ways, including as a monster or some other abstract concept. It's essential for guardians to provide comfort and reassurance to toddlers who may experience fear or confusion about death. Providing simple and concrete explanations about death, tailored to their developmental level, can help alleviate anxiety.
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