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 A
Explanation
Choice A reason: A gluten-free diet is essential for managing celiac disease, as gluten can trigger harmful immune responses in affected individuals. This diet excludes all forms of wheat, barley, rye, and oats unless they are labeled gluten-free.
Choice B reason: A high-fiber diet is generally healthy but is not specifically related to the management of celiac disease. During exacerbations, it is more important to ensure that all foods are gluten-free to avoid triggering symptoms.
Choice C reason: There is no need for a low-protein diet in celiac disease management. Protein is not related to the immune response triggered by gluten.
Choice D reason: Wheat flour contains gluten and must be avoided in a gluten-free diet. Alternative flours such as rice, corn, or gluten-free blends should be used instead.
Correct Answer is B
Explanation
Choice A reason: Applying tepid water to the old dressings can help with their removal and may reduce discomfort, but it does not address the greatest risk to the client, which is infection.
Choice B reason: Checking the wound sites for manifestations of infection is crucial as burn injuries compromise the skin's protective barrier, making the client highly susceptible to infections. Infections can lead to further complications and delay healing.
Choice C reason: Performing passive range-of-motion exercises is important for maintaining joint mobility and preventing contractures in burn patients, but it is not the primary intervention for addressing the greatest risk of infection.
Choice D reason: Adjusting the room temperature to 33°C (91.4°F) can create a more comfortable environment for the burn patient and prevent hypothermia, but it is not directly related to the prevention of infection, which is the greatest risk.
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