A child is admitted with a suspected diagnosis of Wilms tumor. The nurse should place a sign with which of the following warnings over the child's bed?
Do not palpate abdomen
Contact precautions
Collect all urine
No venipuncture or blood pressure in left arm
The Correct Answer is A
A. Do not palpate abdomen: Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. Palpation of the abdomen in a child with Wilms tumor can potentially rupture the tumor capsule and lead to dissemination of cancer cells or cause bleeding. Therefore, it is essential to instruct healthcare providers and caregivers not to palpate the child's abdomen to avoid complications.
B. Contact precautions: Contact precautions are not typically indicated for Wilms tumor. Contact precautions are implemented to prevent the transmission of infectious agents that are spread by direct or indirect contact with the client or their environment. Wilms tumor is not contagious and does not require contact precautions.
C. Collect all urine: While collecting urine may be necessary for diagnostic purposes and monitoring kidney function in a child with Wilms tumor, it is not the primary warning associated with the condition. The priority warning for Wilms tumor focuses on avoiding palpation of the abdomen to prevent potential complications.
D. No venipuncture or blood pressure in left arm: While venipuncture or blood pressure measurement in the left arm may be contraindicated in some situations, such as when a client has a central venous catheter or arteriovenous fistula, it is not specifically associated with Wilms tumor. The primary concern with Wilms tumor is to avoid palpation of the abdomen due to the risk of tumor rupture and dissemination of cancer cells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fidelity: Fidelity refers to the duty to fulfill one's commitments and obligations. While important in nursing practice, fidelity is not directly applicable to the decision not to administer pain medication in this scenario.
B. Veracity: Veracity refers to truthfulness and honesty in communication. While it is important for the nurse to communicate honestly with the client and their family about the risks and benefits of pain management, the decision not to administer pain medication is primarily based on the principle of non-maleficence.
C. Utilitarianism: Utilitarianism is an ethical theory that emphasizes the greatest good for the greatest number of people. While pain relief may contribute to the overall well-being of the client, the decision not to administer pain medication in this scenario is more closely aligned with the principle of non-maleficence, as it focuses on avoiding harm to the individual client.
D. Non-maleficence: Non-maleficence is the ethical principle that emphasizes the duty to do no harm. In this situation, the nurse's primary concern is to avoid causing harm to the client. Administering pain medication to relieve suffering, even if it might hasten death, aligns with the principle of non-maleficence because the intent is to alleviate suffering and provide comfort to the dying client.
Correct Answer is D
Explanation
A. Relieve the client's pain: While pain management is important for client comfort and recovery, it is not the priority immediately following intermaxillary fixation. Pain relief can be addressed once the more urgent concerns, such as preventing aspiration, are addressed.
B. Promote oral hygiene: Promoting oral hygiene is essential for preventing complications such as infection, but it is not the priority immediately after surgery and intermaxillary fixation. The client's airway and respiratory status should be the primary focus at this time.
C. Ensure adequate nutrition: Ensuring adequate nutrition is important for the client's overall recovery, but it is not the immediate priority after surgery and intermaxillary fixation. The priority is to prevent complications such as aspiration and maintain the client's airway.
D. Prevent aspiration: This is the priority action for the nurse. Intermaxillary fixation restricts the client's ability to open their mouth, increasing the risk of aspiration if vomiting occurs. The nurse should ensure that the client's airway is clear and that measures are in place to prevent aspiration, such as positioning the client appropriately and monitoring for signs of respiratory distress.
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