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?

Measuring the child's abdominal circumference

Palpating the child's abdomen

Providing clear liquids up to 1 hr prior to surgery

Continuously monitoring the child's oxygen saturation

Answer and Explanation

The Correct Answer is A

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Reye syndrome causes fatty changes in the liver."

This statement is correct. Reye syndrome is characterized by acute non-inflammatory encephalopathy and fatty changes in the liver, which can lead to liver dysfunction and failure.

B. "Reye syndrome leads to venous thrombus formation."

This statement is incorrect. Reye syndrome primarily affects the brain and liver, leading to cerebral edema and liver dysfunction. It does not typically involve venous thrombus formation.

C. "Reye syndrome is associated with misuse of acetaminophen."

This statement is incorrect. While the exact cause of Reye syndrome is not fully understood, it is not associated with the misuse of acetaminophen. However, there is a well-established association between Reye syndrome and the use of aspirin (salicylates) during viral infections, particularly in children and adolescents.

D. "Reye syndrome is linked to decreased serum ammonia levels."

This statement is incorrect. Reye syndrome is associated with increased serum ammonia levels due to liver dysfunction and impaired ammonia metabolism. Elevated ammonia levels can contribute to the encephalopathy seen in Reye syndrome.

A. Weight gain B. Bradypnea C. Pain D. Diarrhea

Correct Answer is C

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a pediatric clinic is discussing the pathophysiology of Reye syndrome with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicate an understanding of the disorder?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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