A nurse is caring for a 7-year-old child who has acute glomerulonephritis. Which of the following findings is the priority for the nurse to report to the provider?
BP 150/90 mmHg
BUN 20 mg/dL
Urine protein 12 mg/dL
2+ pedal edema
The Correct Answer is A
Choice A reason: A blood pressure reading of 150/90 mmHg is significantly high for a 7-year-old child and indicates hypertension, which can be a serious complication of acute glomerulonephritis. It is a priority to report this finding to the provider as it may require immediate intervention.
Choice B reason: A BUN level of 20 mg/dL is within the normal range for children and is not typically a cause for immediate concern. However, it should be monitored along with other kidney function tests.
Choice C reason: Urine protein of 12 mg/dL is a common finding in acute glomerulonephritis due to increased permeability of the glomerular membrane. It is important but not as urgent as the blood pressure finding.
Choice D reason: 2+ pedal edema is a sign of fluid retention, which is expected in acute glomerulonephritis. While it should be addressed, it is not as immediately concerning as severe hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Teaching the child about cast care is important, but it is not the first action to take. Education on cast maintenance and activity restrictions will follow after addressing immediate needs.
Choice B reason: Administering pain medication should be the first action taken by the nurse. After a cast application for a fracture, the child is likely experiencing pain, and managing this pain is a priority to ensure comfort and facilitate healing.
Choice C reason: Elevating the child's leg is a subsequent action that can help reduce swelling and discomfort, but it is not the first action to take. Pain management is the priority before positioning.
Choice D reason: Petaling the edges of the cast, which involves placing soft material around the rough edges to prevent skin irritation, is important but not the first action. The initial focus should be on pain relief.
Correct Answer is A
Explanation
Choice A reason: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.
Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.
Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.
Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.
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