This chapter is from the book
This chapter is from the book
This chapter is from the book
Answer Rationales
1. Answer A is correct. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis. The medication takes effect within one month of beginning therapy, so answer B is incorrect. The medication should be taken with water. Fruit juice, particularly grapefruit juice, can decrease the drug’s effectiveness, so answer C is incorrect. Liver function studies, not a CBC, should be checked prior to beginning the medication, so answer D is incorrect.
2. Answer B is correct. Hyperstat is given IV push for hypertensive crisis. It often causes hyperglycemia. The glucose level will drop rapidly after the medication is administered. Answer A is incorrect because this medication is given IV push. The client should be placed in dorsal recumbent position, not Trendelenburg, so answer C is incorrect. Answer D is incorrect because the medication is ordered IV push.
3. Answer C is correct. A heart rate of 60 in the six-month-old receiving Lanoxin elixir (digoxin) should be reported immediately because bradycardia is associated with digoxin toxicity. The blood glucose, blood pressure, and respirations are not associated with administration of Lanoxin, so answers A, B, and D are incorrect.
4. Answer C is correct. The client should leave the medication in the brown bottle because light deteriorates the medication. The supply should be replenished every six months, so answer A is incorrect. One tablet should be taken every five minutes times three, so answer B is incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, so answer D is incorrect.
5. Answer D is correct. CK-MB (creatine phosphokinase muscle bond isoenzyme) is the most specific for a myocardial infarction. Troponin is also extremely reliable. Answers A, B, and C are nonspecific to myocardial infarctions, so they are incorrect.
6. Answer C is correct. Turkey contains the least amount of fat and cholesterol. Cheese, shrimp, and beef should be avoided by the client on a low cholesterol, low fat diet; therefore, answers A, B, and D are incorrect.
7. Answer B is correct. The neck veins should be assessed for distension in the client with congestive heart failure. Edema of the feet and hands does not indicate central circulatory overload, so answers A and C are incorrect. Edema of the sacrum is an indication of right-sided congestive heart failure, so answer D is incorrect.
8. Answer A is correct. The nurse should place the zero of the manometer at the phlebostatic axis (located at the fifth intercostal space mid-axillary line) when checking the central venous pressure. Answers B, C, and D are incorrect methods for determining the central venous pressure.
9. Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix. There is no need to question the order, give the drugs separately, or contact the pharmacy, so answers A, C, and D are incorrect.
10. Answer B is correct. The best method for evaluating the amount of peripheral edema is measuring the extremity. A paper tape measure should be used rather than plastic or cloth, and the area should be marked with a pen. This provides the most objective assessment. Answers A, C, and D are not the best methods for evaluating the amount of peripheral edema, therefore they are incorrect.
