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NurseDive Free Nursing Practice Question
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?
A. Measuring the child's abdominal circumference
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: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 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
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.
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Full Explanation
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.
Similar Questions
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take?
A. Obtain a daily weight.
Obtain a daily weight:This is an appropriate action. Monitoring daily weights can help assess fluid balance and detect fluid retention, which is common in children with kidney disorders like acute glomerulonephritis. Sudden weight gain or fluid overload may indicate worsening kidney function and the need for intervention.
B. Strain the urine.
Strain the urine:Straining the urine may be indicated to monitor for the presence of blood or protein, which are common findings in acute glomerulonephritis. Straining the urine is not necessary, as hematuria is a common finding and does not indicate kidney damage.
C. Monitor blood glucose level every 4 hr.
Monitor blood glucose level every 4 hr: Monitoring blood glucose levels every 4 hours is not directly related to the care of a child with acute glomerulonephritis. Blood glucose monitoring is more relevant in conditions such as diabetes mellitus. However, monitoring electrolyte levels, including blood glucose, may be part of routine laboratory testing in children with kidney disorders.
D. Recommend strict bed rest.
Recommend strict bed rest:Strict bed rest is not typically recommended for children with acute glomerulonephritis unless there are specific complications or severe symptoms requiring immobilization. While some activity restriction may be recommended during the acute phase of the illness, strict bed rest may lead to complications such as deconditioning and venous thromboembolism.
Full Explanation
A. Obtain a daily weight:
This is an appropriate action. Monitoring daily weights can help assess fluid balance and detect fluid retention, which is common in children with kidney disorders like acute glomerulonephritis. Sudden weight gain or fluid overload may indicate worsening kidney function and the need for intervention.
B. Strain the urine:
Straining the urine may be indicated to monitor for the presence of blood or protein, which are common findings in acute glomerulonephritis. Straining the urine is not necessary, as hematuria is a common finding and does not indicate kidney damage.
C. Monitor blood glucose level every 4 hr:
Monitoring blood glucose levels every 4 hours is not directly related to the care of a child with acute glomerulonephritis. Blood glucose monitoring is more relevant in conditions such as diabetes mellitus. However, monitoring electrolyte levels, including blood glucose, may be part of routine laboratory testing in children with kidney disorders.
D. Recommend strict bed rest:
Strict bed rest is not typically recommended for children with acute glomerulonephritis unless there are specific complications or severe symptoms requiring immobilization. While some activity restriction may be recommended during the acute phase of the illness, strict bed rest may lead to complications such as deconditioning and venous thromboembolism.
A nurse is assessing a child who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the following clinical manifestations should the nurse expect?
A. Weight gain
Weight gain:Weight gain is not typically associated with vasoocclusive crisis in sickle cell anemia. In fact, individuals may experience dehydration and weight loss due to increased metabolic demands during a crisis.
B. Bradypnea
Bradypnea:Bradypnea, or slow breathing, is not a characteristic feature of vasoocclusive crisis in sickle cell anemia. Respiratory rate may be normal or increased due to pain or compensatory mechanisms.
C. Pain
Pain: This is the correct option. Pain is the hallmark manifestation of vasoocclusive crisis in sickle cell anemia. The pain can occur anywhere in the body but most commonly affects the bones, joints, abdomen, and chest. The severity of pain can vary from mild to severe and may require hospitalization for pain management.
D. Diarrhea
Diarrhea:Diarrhea is not typically associated with vasoocclusive crisis in sickle cell anemia. Gastrointestinal symptoms such as abdominal pain and nausea may occur, but diarrhea is not a common manifestation of vasoocclusive crisis.
Full Explanation
A. Weight gain:
Weight gain is not typically associated with vasoocclusive crisis in sickle cell anemia. In fact, individuals may experience dehydration and weight loss due to increased metabolic demands during a crisis.
B. Bradypnea:
Bradypnea, or slow breathing, is not a characteristic feature of vasoocclusive crisis in sickle cell anemia. Respiratory rate may be normal or increased due to pain or compensatory mechanisms.
C. Pain:
This is the correct option. Pain is the hallmark manifestation of vasoocclusive crisis in sickle cell anemia. The pain can occur anywhere in the body but most commonly affects the bones, joints, abdomen, and chest. The severity of pain can vary from mild to severe and may require hospitalization for pain management.
D. Diarrhea:
Diarrhea is not typically associated with vasoocclusive crisis in sickle cell anemia. Gastrointestinal symptoms such as abdominal pain and nausea may occur, but diarrhea is not a common manifestation of vasoocclusive crisis.
A nurse is caring for a child who is experiencing status asthmaticus. Which of the following actions should the nurse take first?
A. Initiate an infusion of IV fluids.
Initiate an infusion of IV fluids:Administering IV fluids may be necessary to maintain hydration and support circulation, but it is not the first action to take in managing status asthmaticus. In this acute situation, the priority is to address airway obstruction and respiratory distress.
B. Obtain a blood specimen for ABG analysis.
Obtain a blood specimen for ABG analysis:Obtaining arterial blood gas (ABG) analysis can provide valuable information about the child's respiratory status, including oxygenation and acid-base balance. However, it is not the first action to take in managing status asthmaticus.
C. Administer a dose of an IV corticosteroid.
Administer a dose of an IV corticosteroid: Administering systemic corticosteroids (such as IV hydrocortisone or methylprednisolone) is a crucial intervention in managing status asthmaticus to reduce airway inflammation and improve respiratory function. However, it is not the first action to take.
D. Apply humidified oxygen.
Apply humidified oxygen:This is the correct action to take first. Applying humidified oxygen helps improve oxygenation and relieve bronchospasm by providing supplemental oxygen to the child's lungs. Oxygen therapy is essential in managing respiratory distress associated with status asthmaticus and should be initiated promptly.
Full Explanation
A. Initiate an infusion of IV fluids:
Administering IV fluids may be necessary to maintain hydration and support circulation, but it is not the first action to take in managing status asthmaticus. In this acute situation, the priority is to address airway obstruction and respiratory distress.
B. Obtain a blood specimen for ABG analysis:
Obtaining arterial blood gas (ABG) analysis can provide valuable information about the child's respiratory status, including oxygenation and acid-base balance. However, it is not the first action to take in managing status asthmaticus.
C. Administer a dose of an IV corticosteroid:
Administering systemic corticosteroids (such as IV hydrocortisone or methylprednisolone) is a crucial intervention in managing status asthmaticus to reduce airway inflammation and improve respiratory function. However, it is not the first action to take.
D. Apply humidified oxygen:
This is the correct action to take first. Applying humidified oxygen helps improve oxygenation and relieve bronchospasm by providing supplemental oxygen to the child's lungs. Oxygen therapy is essential in managing respiratory distress associated with status asthmaticus and should be initiated promptly.