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. "Apply a dry gauze dressing twice per day."
This instruction may not be necessary for a hypospadias repair procedure. Typically, the surgical site will have a dressing applied immediately after the surgery, but ongoing dressing changes may not be required once the infant is discharged. It's essential to follow the specific postoperative care plan provided by the healthcare provider.
B. "Perform hourly measurements of the infant's urinary output."
Hourly measurements of urinary output may not be necessary unless specifically instructed by the healthcare provider due to concerns such as urinary retention or dehydration. However, regular monitoring of urinary output as part of routine care may be appropriate.
C. "Offer the infant 12 to 18 ounces of fruit juice daily."
Offering 12 to 18 ounces of fruit juice daily to a 6-month-old infant is not recommended. Introduction of fruit juice should be gradual and in small amounts, following guidance from healthcare providers and infant nutrition guidelines. Excessive fruit juice consumption can lead to gastrointestinal issues and may not be suitable for all infants.
D. "Avoid giving the infant a tub bath until the stent is removed."
This instruction is appropriate. After hypospadias repair surgery, a stent or catheter may be placed to aid in healing and ensure proper urine drainage. It's essential to follow healthcare provider instructions regarding bathing and hygiene to minimize the risk of infection and to ensure the stent remains in place until it is ready to be removed.
Correct Answer is A
Explanation
A. Oucher pain rating scale: The Oucher pain rating scale uses pictures of children's faces to represent varying degrees of pain intensity. This scale is specifically designed for young children and can be effective in assessing pain in preschool-aged children who may not yet be able to accurately use verbal descriptors to express their pain.
B. Word-Graphic rating scale: This type of scale presents both words and pictures to represent different levels of pain intensity. While it may be suitable for older children who can understand and use words to describe their pain, it may be less effective for a 4-year-old child who is still developing language skills.
C. Numeric rating scale: Numeric rating scales typically ask the child to rate their pain on a scale from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. While this scale may be appropriate for older children, it may be challenging for a 4-year-old to understand and use numbers to describe their pain.
D. Visual analog scale: Visual analog scales typically consist of a line with endpoints labeled "no pain" and "worst pain imaginable," with the child asked to mark or point to the spot on the line that represents their pain level. While this scale may be suitable for older children and adults, it may be too abstract for a 4-year-old child to understand and use effectively.

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