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 {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale:
- Pain: The client is reporting intense pain (10 on a 0 to 10 scale) in his left arm, and he is unable to move it. This suggests a possible fracture or significant soft tissue injury. Managing this pain is the priority to ensure the client’s comfort and prevent further complications.
- Compartment syndrome: Given the swelling, bruising, and coolness to the touch in the left arm, compartment syndrome is a serious risk. This occurs when swelling or bleeding in a muscle compartment increases pressure, potentially compromising blood flow to muscles and nerves. Immediate interventions are required to prevent tissue damage.
Rationale for Incorrect Options:
- Swelling: While swelling is present, it is a natural part of the healing process and not the primary concern in this case. The risk of compartment syndrome is much more urgent than managing swelling.
- Mobility: The client’s mobility is impaired due to pain, but pain management must be prioritized before focusing on restoring mobility. Only once pain is controlled should mobility be addressed.
- Fat embolism syndrome: Although fat embolism syndrome is a risk in traumatic fractures, especially with long bone injuries, the symptoms of this client (swelling, bruising, cool arm) point more directly to the risk of compartment syndrome rather than fat embolism syndrome.
- Venous thromboembolism (VTE): VTE is a concern in immobilized patients, but in the acute phase, compartment syndrome poses a more immediate threat. The priority is to manage the current trauma and risk for compartment syndrome before considering VTE prevention.
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