A nurse is providing care to a 7-year-old male client in the primary care office for a blood pressure check.
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- Heart rate: 75/min
- Pulse oximetry: 98% on room air
- Blood pressure: 148/88 mm Hg
- Height: 154.9 cm (61 inches)
- Weight: 44.5 kg (98 lb)
Heart rate: 75/min
Pulse oximetry: 98% on room air
Blood pressure: 148/88 mm Hg
Height: 154.9 cm (61 inches)
Weight: 44.5 kg (98 lb)
The Correct Answer is ["C"]
Choice A rationale: A heart rate of 75/min in a 7-year-old child falls within the normal pediatric range of 70 to 110 beats per minute. Heart rate variability can be influenced by activity, anxiety, or health status. Since this child is alert and cooperative with no signs of distress, this heart rate is physiologically appropriate and does not indicate an urgent cardiovascular problem requiring immediate follow-up.
Choice B rationale: A pulse oximetry reading of 98% on room air is considered within normal limits for a child. Normal oxygen saturation ranges from 95% to 100% in healthy individuals, indicating adequate oxygenation and effective pulmonary gas exchange. Since the child shows no respiratory distress and oxygen saturation is stable, no immediate intervention is necessary based on this value.
Choice C rationale: A blood pressure of 148/88 mm Hg in a 7-year-old is significantly elevated. Pediatric hypertension is defined as systolic or diastolic BP at or above the 95th percentile for age, sex, and height. For this age and height, normal systolic BP is approximately 90–112 mm Hg, and diastolic is 55–75 mm Hg. This reading suggests stage 2 hypertension, requiring urgent evaluation to prevent end-organ damage.
Choice D rationale: Height of 154.9 cm (61 inches) at age 7 is above average but not concerning by itself. Growth charts indicate the 95th percentile for 7-year-old boys is around 128 cm (50 inches). This height is unusually tall, likely indicating early growth spurt or familial tall stature but does not require immediate clinical follow-up unless accompanied by other symptoms.
Choice E rationale: Weight of 44.5 kg (98 lb) at age 7 is significantly above the typical weight range, with the 95th percentile approximately 34 kg. This child is likely obese, which predisposes to hypertension and metabolic complications. However, obesity alone is not an immediate threat requiring urgent follow-up, but it warrants lifestyle counseling and monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Biopsy of the tumor is the definitive diagnostic procedure for Wilms tumor. This involves the surgical removal of a tissue sample from the suspected mass, which is then examined microscopically by a pathologist. Histopathological analysis confirms the presence of malignant cells characteristic of nephroblastoma, differentiating it from other renal masses and guiding subsequent treatment protocols. Normal renal tissue structure is preserved in healthy kidneys.
Choice B rationale
Bone marrow aspiration is primarily used to diagnose hematological malignancies or assess for metastatic disease in certain cancers. While Wilms tumor can metastasize, particularly to the lungs, bone marrow involvement is uncommon and not the primary diagnostic method for confirming the initial diagnosis of the tumor itself. Normal bone marrow contains hematopoietic stem cells and a balanced cellularity.
Choice C rationale
A CT scan of the abdomen and chest provides detailed anatomical information about the tumor's size, location, and extent of involvement within the kidney and surrounding structures, as well as checking for metastasis to the lungs. While crucial for staging and surgical planning, a CT scan is an imaging modality and does not provide a definitive tissue diagnosis. Normal abdominal organs appear with distinct densities.
Choice D rationale
Abdominal ultrasonography is often the initial imaging modality used to evaluate a suspected abdominal mass in children due to its non-invasive nature and lack of radiation exposure. It can identify the presence of a renal mass and distinguish between solid and cystic lesions, but like CT, it cannot definitively diagnose Wilms tumor without tissue sampling. Normal kidneys appear as solid, homogeneous organs.
Correct Answer is ["1.9"]
Explanation
Step 1 is to determine the concentration of the reconstituted medication. The vial contains 4g and is reconstituted with 12mL for a final concentration of 2g per 2.5mL.
Step 2 is to calculate how many mL are needed for the 1.5g dose. The desired dose is 1.5g. The concentration is 2g in 2.5mL.
Step 3 is to set up a proportion: (2g ÷ 2.5mL) = (1.5g ÷ X mL).
Step 4 is to solve for X: X mL = (1.5g × 2.5mL) ÷ 2g.
Step 5 is to calculate the value: X = 3.75 ÷ 2.
Step 6 is to calculate the final answer: X = 1.875 mL.
Step 7 is to round to the nearest tenth: 1.9 mL. The final calculated answer is 1.9 mL.
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