A 3-year-old child is admitted with a Stage II Wilm's tumor. Which preoperative intervention(s) should the nurse implement? Choose all that apply.
Explain expected side effects of postoperative chemotherapy.
Monitor blood pressure every 2 hours for hypertension.
Provide parents with simple explanations and repeat often.
Attend all healthcare provider and parent conferences.
Measure the child's abdominal girth.
Correct Answer : B,C,E
A. Explain expected side effects of postoperative chemotherapy: Chemotherapy and its side effects are typically discussed after surgery when the treatment plan is clearer. The focus before surgery should be on preparing the child and family for the surgery itself.
B. Monitor blood pressure every 2 hours for hypertension: Wilm's tumor can be associated with hypertension due to renin production from the tumor, so monitoring the child's blood pressure closely is essential to detect any signs of hypertension early.
C. Provide parents with simple explanations and repeat often: Simplified, repeated explanations are key to helping parents understand the diagnosis and surgical procedure. This approach supports emotional comfort and ensures informed decision-making.
D. Attend all healthcare provider and parent conferences: While it is important to support the family, the nurse’s role in attending all healthcare provider and parent conferences is not mandatory unless specifically needed for continuity of care.
E. Measure the child's abdominal girth: Measuring abdominal girth is essential preoperatively to monitor for any abdominal changes, such as swelling or distension, which could indicate tumor growth or other complications related to the Wilm's tumor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Observe insertion site: The nurse should assess the suprapubic catheter insertion site for signs of infection, redness, or other complications. This is crucial to ensure the catheter is functioning correctly and to prevent infection.
B. Assess perineal area: The perineal area is not directly related to the suprapubic catheter, as it is inserted into the bladder through the abdomen. The focus should be on the insertion site and the catheter itself.
C. Measure abdominal girth: While measuring abdominal girth could be important if the client has issues such as fluid retention or urinary retention, it is not the primary focus for routine assessment of a suprapubic catheter.
D. Palpate flank area: The flank area may be relevant for kidney assessment, but for a suprapubic catheter, the primary focus should be on the catheter insertion site and its function.
Correct Answer is C
Explanation
A. Auscultate for bowel sounds in all quadrants: While assessing bowel sounds can help evaluate gastrointestinal function, it does not assess the effectiveness of a proton pump inhibitor. PPIs primarily work to reduce gastric acid secretion, not to change bowel sounds.
B. Measure the client's fluid intake and output: Measuring fluid intake and output is important for general fluid balance but does not specifically assess the effectiveness of a PPI. This action is more relevant to other concerns such as hydration status.
C. Ask the client about gastrointestinal pain: The primary indication for PPIs is the treatment of gastrointestinal conditions like acid reflux, ulcers, or GERD. Asking the client about gastrointestinal pain directly assesses the effectiveness of the PPI in reducing symptoms such as heartburn or discomfort.
D. Monitor the client's serum electrolyte levels: While electrolyte imbalances can be a concern with prolonged PPI use, monitoring electrolytes is not the immediate method to assess PPI effectiveness. Reduction in gastrointestinal symptoms is a more direct indicator.
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