Nokea
Which of the following is least considered to be a normal variant in newborns?
- A. Milia
- B. Neonatal pustular melanosis
- C. Dermal melanocytosis
- D. Infantile acropustulosis
Correct Answer: D
Rationale: Infantile acropustulosis is not considered a normal variant in newborns; it is a rare condition characterized by recurrent pustular eruptions.
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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.
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.
A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?
- A. What time did he take his last medications?
- B. Has his weight changed in the last several days?
- C. Is he still able to tighten his belt buckle?
- D. How many hours did he sleep last night?
Correct Answer: B
Rationale: Weight gain is a key indicator of fluid retention in heart failure, which can exacerbate symptoms.
What should the nurse assess prior to administering digoxin? (Select all that apply.)
- A. Sclera
- B. Apical pulse rate
- C. Cough
- D. Liver function test
Correct Answer: B
Rationale: Because digoxin decreases the heart rate, the apical pulse should be assessed. If the HR is below 60 beats per minute, digoxin should not be administered.
Concerning SLE:
- A. Antibodies against double standard RNA are a typical finding
- B. Haematoxylin bodies occur in areas of inflammation
- C. Usually progresses to renal failure within two years
- D. Alopecia is a recognised finding
Correct Answer: D
Rationale: Alopecia is a recognized clinical feature of systemic lupus erythematosus (SLE), often associated with disease activity.