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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Hypothermia is not a common finding associated with inhalation of gasoline. It typically occurs due to exposure to cold temperatures and is not related to chemical inhalation.

Choice B reason: Hyperactive reflexes are not typically associated with gasoline inhalation. They can be a sign of neurological disorders or a response to certain medications, but not commonly from inhalants.

Choice C reason: Mydriasis, which is the dilation of the pupils, can occur with inhalation of gasoline due to its effect on the nervous system. It is a sign that the nurse should be aware of during the assessment.

Choice D reason: Pinpoint pupils are more commonly associated with opioid overdose and not with inhalation of gasoline. The nurse should expect to see dilated pupils rather than constricted ones.

A. Upper respiratory infection 2 days ago B. Temperature of 37.2° C (99°F) C. Family history of seizures D. Allergy to neomycin

Correct Answer is D

Explanation

Choice Areason: An upper respiratory infection 2 days ago, if the child is currently well, is not a contraindication for the MMR vaccine. Vaccines can be given to children with a minor illness.

Choice Breason: A temperature of 37.2° C (99°F) is a mild elevation and is not a contraindication for receiving the MMR vaccine. Vaccination can proceed if the child is only mildly ill.

Choice C reason: A family history of seizures is not a contraindication for the MMR vaccine. While there is a small risk of febrile seizures, the benefits of vaccination outweigh the risks.

Choice D reason: An allergy to neomycin is a contraindication for the MMR vaccine because neomycin is used in the vaccine production process. Children with a known severe allergic reaction to neomycin should not receive the vaccine.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication for receiving this vaccine?

Correct Answer is D

Explanation

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