Nokea
A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes,. Which assessment should the nurse implement first?
- A. Evaluate distal capillary refill for delayed perfusion
- B. Check the extremities for bruising and petechiae
- C. Examine the pretibial regions for pitting edema
- D. Palpate the abdomen for tenderness and rigidity
Correct Answer: D
Rationale: Palpating the abdomen helps assess for complications such as peritonitis or worsening ascites.
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All the following are causes of heart failure in full-term neonate EXCEPT
- A. asphyxial
- B. coarctation of aorta
- C. hypoplastic left heart syndrome
- D. transposition of great arteries
Correct Answer: B
Rationale: Coarctation of the aorta may not immediately present with heart failure in full-term neonates.
Regarding cisapride:
- A. It is licensed for use in children
- B. Fatal arrhythmias have been reported
- C. Concurrent administration with erythromycin is not advised
- D. It commonly causes constipation
Correct Answer: B
Rationale: Fatal arrhythmias have been reported: Cisapride, a gastrointestinal prokinetic agent, has been linked to fatal arrhythmias, particularly when combined with certain drugs like erythromycin.
The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is required, round to the nearest tenth.)
- A. 0.9
- B. 1
- C. 9
Correct Answer: A
Rationale: The calculation is based on the prescribed dose and the concentration of the medication.
What should the school nurse recommend when encouraging a heart-healthy diet for a child with high cholesterol?
- A. A fat intake reduction of 5-10% of total calories
- B. A fat intake reduction of 10-15% of total calories
- C. A fat intake reduction of 15-20% of total calories
- D. A fat intake reduction of 25-35% of total calories
Correct Answer: D
Rationale: For a child with increased cholesterol, a fat reduction of 25-35% of total calories with less than 75 saturated fat and less than 200 mg of cholesterol per day is advised.
The following are causes of congestive heart failure and cardiomegaly during the newborn period but no murmur EXCEPT
- A. endocardial fibroelastosis
- B. asphyxia
- C. glycogen storage disease (Pompe disease)
- D. sepsis
Correct Answer: D
Rationale: Sepsis can cause heart failure and cardiomegaly but often presents with other systemic signs.