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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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.
Complement system:
- A. Is activated by bacterial endotoxins by the classical pathway
- B. Reduced C3 and C4 are usual findings in acute glomerulonephritis
- C. Hereditary angioneurotic oedema is caused by deficiency of one of the components of the classical pathway of the system
- D. Is part of humoral immunity
Correct Answer: D
Rationale: The complement system is a key component of humoral immunity, playing a role in the immune response to pathogens.
Prior to the patient being given medication, he becomes hypotensive, mottled, and cold. His heart rate is 240. The next therapeutic step should be
- A. digoxin
- B. synchronized DC cardioversion
- C. lidocaine
- D. defibrillation
Correct Answer: B
Rationale: Synchronized DC cardioversion is indicated for unstable tachycardia unresponsive to pharmacological agents.
Coarctation of aorta is:
- A. Commonly associated with Turner's syndrome
- B. Inherited as autosomal dominant
- C. Associated with intracranial aneurysms
- D. Excluded from the diagnosis in the presence of femoral pulses
Correct Answer: A
Rationale: Coarctation of the aorta is commonly associated with Turner's syndrome, a chromosomal condition affecting females.
Obesity in childhood:
- A. Is usually associated with hypogonadism
- B. Is unlikely to lead to adult obesity
- C. Is more common in families in Social Class I than in Social Class V
- D. Can lead to overestimation of the dose of intravenous fluids when these are required
Correct Answer: C
Rationale: Childhood obesity is more common in higher social classes. It is not typically associated with hypogonadism and can lead to adult obesity. Overestimation of fluid doses is not a recognized issue.