The mother of a 4-year-old client tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that their child is eating well and that their activity level is unchanged. The nurse, suspecting the possibility of Wilms tumor, should avoid which action during the physical assessment?
Monitoring the temperature for the presence of fever
Monitoring the blood pressure for the presence of hypertension
Assessing the urine for the presence of hematuria
Palpating the abdomen for a mass
The Correct Answer is D
A. Monitoring the temperature for fever is appropriate as part of a general assessment and could help identify signs of infection.
B. Monitoring blood pressure is important because hypertension can be associated with Wilms tumor.
C. Assessing the urine for hematuria is appropriate, as hematuria can be a symptom of Wilms tumor.
D. Palpating the abdomen is contraindicated in suspected Wilms tumor cases because it could cause the tumor to rupture, potentially spreading cancerous cells. Therefore, palpating the abdomen should be avoided until further diagnostic procedures are performed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acetaminophen can be used to manage mild discomfort after cardiac catheterization. It is a safe option for pain relief and is commonly recommended for children following the procedure.
B. Bed rest is typically recommended for a shorter duration, often 24 hours, not a full week. Extended bed rest is not usually required unless complications occur.
C. The diet should be advanced as tolerated, but there is no specific requirement to wait 24 hours; this will depend on the child’s recovery and tolerance.
D. Bathing recommendations often include avoiding submerging the site in water, so a tub bath may not be advised for the first few days to prevent infection. Sponge baths might be recommended instead.
Correct Answer is A
Explanation
A. Keeping a dedicated thermometer in the toddler's room is an appropriate infection control measure to prevent cross-contamination with other patients.
B. RSV is primarily transmitted through droplet and contact, not airborne, so contact and droplet precautions are more appropriate than airborne precautions.
C. Nebulized racemic epinephrine is not typically used for RSV; it is more commonly used for croup. Treatment for RSV may include supportive care such as hydration and oxygen therapy.
D. While monitoring pulse oximetry is important, assessing it every 3 hours might be insufficient. Continuous monitoring may be more appropriate depending on the severity of the illness.
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