Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. BP 150/90 mmHg
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.
B. BUN 20 mg/dL
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.
C. Urine protein 12 mg/dL
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.
D. 2+ pedal edema
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.
This question is an excerpt from Nurse Dive's nursing test bank - RN ATI Nursing Care of Children 2019 Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is preparing to administer immunizations to a 3-month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?
A. Use a 20-gauge needle for the injections.
Using a 20-gauge needle for injections in a 3-month-old infant is not appropriate as it is too large. A smaller gauge needle should be used to minimize pain and tissue trauma.
B. Provide a pacifier coated with an oral sucrose solution prior to the injections.
Providing a pacifier coated with an oral sucrose solution prior to the injections is an evidence-based practice to reduce pain in infants. The sweet taste of sucrose has a soothing effect and can help to distract the infant from the discomfort of the injection.
C. Inject the immunizations into the deltoid muscle.
Injecting immunizations into the deltoid muscle is not recommended for a 3-month-old infant as their muscle mass is not yet fully developed. The anterolateral thigh is the preferred site for intramuscular injections in infants.
D. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections.
Applying eutectic mixture of local anesthetics (EMLA) cream immediately before the injections can help to numb the skin and reduce pain. However, it needs to be applied at least one hour before the procedure to be effective.
Full Explanation
Choice A reason: Using a 20-gauge needle for injections in a 3-month-old infant is not appropriate as it is too large. A smaller gauge needle should be used to minimize pain and tissue trauma.
Choice B reason: Providing a pacifier coated with an oral sucrose solution prior to the injections is an evidence-based practice to reduce pain in infants. The sweet taste of sucrose has a soothing effect and can help to distract the infant from the discomfort of the injection.
Choice C reason: Injecting immunizations into the deltoid muscle is not recommended for a 3-month-old infant as their muscle mass is not yet fully developed. The anterolateral thigh is the preferred site for intramuscular injections in infants.
Choice D reason: Applying eutectic mixture of local anesthetics (EMLA) cream immediately before the injections can help to numb the skin and reduce pain. However, it needs to be applied at least one hour before the procedure to be effective.
A nurse is caring for a 4-year-old child who has meningitis and is receiving gentamicin. Which of the following laboratory values should the nurse report to the provider?
A. Creatinine 1.4 mg/dL
A creatinine level of 1.4 mg/dL is higher than the normal range for a 4-year-old child and could indicate kidney impairment, which is a concern when administering gentamicin due to its potential nephrotoxic effects. The provider should be informed immediately to assess kidney function and adjust the medication if necessary.
B. BUN 5 mg/dL
A BUN level of 5 mg/dL is within the normal range for children and does not typically warrant immediate concern. However, it should be monitored along with creatinine levels to assess kidney function.
C. Creatinine 0.3 mg/dL
A creatinine level of 0.3 mg/dL is within the normal range for a 4-year-old child and does not indicate an immediate concern. It should be monitored for any changes, especially when on gentamicin.
D. WBC 15,000/mm³
A WBC count of 15,000/mm³ is slightly elevated, which may be expected in a child with meningitis as it indicates an immune response to infection. However, it is not as critical as an abnormal creatinine level in the context of gentamicin therapy.
Full Explanation
Choice A reason: A creatinine level of 1.4 mg/dL is higher than the normal range for a 4-year-old child and could indicate kidney impairment, which is a concern when administering gentamicin due to its potential nephrotoxic effects. The provider should be informed immediately to assess kidney function and adjust the medication if necessary.
Choice B reason: A BUN level of 5 mg/dL is within the normal range for children and does not typically warrant immediate concern. However, it should be monitored along with creatinine levels to assess kidney function.
Choice C reason: A creatinine level of 0.3 mg/dL is within the normal range for a 4-year-old child and does not indicate an immediate concern. It should be monitored for any changes, especially when on gentamicin.
Choice D reason: A WBC count of 15,000/mm³ is slightly elevated, which may be expected in a child with meningitis as it indicates an immune response to infection. However, it is not as critical as an abnormal creatinine level in the context of gentamicin therapy.
A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines. Which of the following instructions should the nurse include in the teaching?
A. "You can replace milk with non-dairy sources of calcium."
For individuals who are lactose intolerant, it is important to find alternative sources of calcium. Non-dairy sources such as fortified plant-based milks, leafy greens, and calcium-fortified foods can provide the necessary calcium without causing discomfort.
B. "You should consume flavored yogurt instead of plain yogurt."
Flavored yogurt often contains added sugars and may still have lactose, which can cause symptoms in those who are lactose intolerant. It's better to choose lactose-free options or plant-based alternatives.
C. "You might tolerate plain milk better than chocolate milk."
Lactose intolerance means that the body cannot effectively digest lactose found in milk, regardless of whether it is plain or chocolate. Therefore, it is not advisable to consume any milk that contains lactose.
D. "You can drink milk on an empty stomach."
Drinking milk on an empty stomach can actually worsen symptoms for someone who is lactose intolerant. It is better to avoid milk or choose lactose-free alternatives.
Full Explanation
Choice A reason: For individuals who are lactose intolerant, it is important to find alternative sources of calcium. Non-dairy sources such as fortified plant-based milks, leafy greens, and calcium-fortified foods can provide the necessary calcium without causing discomfort.
Choice B reason: Flavored yogurt often contains added sugars and may still have lactose, which can cause symptoms in those who are lactose intolerant. It's better to choose lactose-free options or plant-based alternatives.
Choice C reason: Lactose intolerance means that the body cannot effectively digest lactose found in milk, regardless of whether it is plain or chocolate. Therefore, it is not advisable to consume any milk that contains lactose.
Choice D reason: Drinking milk on an empty stomach can actually worsen symptoms for someone who is lactose intolerant. It is better to avoid milk or choose lactose-free alternatives.