A child is admitted with a suspected diagnosis of Wilms tumor. The nurse should place a sign with which of the following warnings over the child's bed?

Do not palpate abdomen

Contact precautions

Collect all urine

No venipuncture or blood pressure in left arm

Answer and Explanation

The Correct Answer is A

A. Do not palpate abdomen: Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. Palpation of the abdomen in a child with Wilms tumor can potentially rupture the tumor capsule and lead to dissemination of cancer cells or cause bleeding. Therefore, it is essential to instruct healthcare providers and caregivers not to palpate the child's abdomen to avoid complications.
B. Contact precautions: Contact precautions are not typically indicated for Wilms tumor. Contact precautions are implemented to prevent the transmission of infectious agents that are spread by direct or indirect contact with the client or their environment. Wilms tumor is not contagious and does not require contact precautions.
C. Collect all urine: While collecting urine may be necessary for diagnostic purposes and monitoring kidney function in a child with Wilms tumor, it is not the primary warning associated with the condition. The priority warning for Wilms tumor focuses on avoiding palpation of the abdomen to prevent potential complications.
D. No venipuncture or blood pressure in left arm: While venipuncture or blood pressure measurement in the left arm may be contraindicated in some situations, such as when a client has a central venous catheter or arteriovenous fistula, it is not specifically associated with Wilms tumor. The primary concern with Wilms tumor is to avoid palpation of the abdomen due to the risk of tumor rupture and dissemination of cancer cells.

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Correct Answer is C

Explanation

To determine the total number of units of insulin to prepare in the insulin syringe, add together the prescribed doses of regular insulin and NPH insulin.

Regular insulin: 14 units NPH insulin: 28 units

Total: 14 units (regular insulin) + 28 units (NPH insulin) = 42 units

Therefore, the nurse should prepare a total of 42 units of insulin in the insulin syringe: 14 units of regular insulin and 28 units of NPH insulin

A. Stop the enema and document that the client did not tolerate the procedure. B. Encourage the client to bear down C. Lower the height of the solution container D. Allow the client to expel some fluid before continuing

Correct Answer is C

Explanation

A. Stop the enema and document that the client did not tolerate the procedure:
This option may be appropriate if the client's discomfort is severe or if there are signs of distress. However, abdominal cramps are a common sensation during the administration of an enema, especially if the bowel is distended or constipated. Therefore, stopping the procedure may not be necessary at this point.
B. Encourage the client to bear down:
Bearing down might help the client expel the enema solution and relieve some discomfort. However, if the client is already experiencing abdominal cramps, bearing down could exacerbate the discomfort and is not likely to provide immediate relief.
C. Lower the height of the solution container:
This is the correct action to take. Lowering the height of the solution container reduces the flow rate of the enema solution, which can help alleviate abdominal cramps by slowing the rate of distension of the bowel. Slowing the infusion rate allows the client's colon to accommodate to the enema more comfortably.
D. Allow the client to expel some fluid before continuing:
Allowing the client to expel some fluid before continuing may provide some relief, but it does not directly address the cause of the discomfort. Lowering the height of the solution container is a more appropriate action to address the discomfort caused by abdominal cramps during the administration of the enema.

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A child is admitted with a suspected diagnosis of Wilms tumor. The nurse should place a sign with which of the following warnings over the child's bed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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