Answers Part 5
31. Answer B is correct.
The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.
32. Answer A is correct.
The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simulta- neously, making answer C incorrect. The Tail of Spence (the upper outer quadrant of the breast) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect.
33. Answer B is correct.
Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.
34. Answer B is correct.
The best indicator of peripheral edema is measuring the extremi- ty. A paper tape measure should be used rather than one made of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment.
Answer A is incorrect because weighing the client will not indicate peripheral edema.
Answer C is incorrect because checking the intake and output will not indicate periph- eral edema.
Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.
35. Answer D is correct.
Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, put- ting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important.
Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.
36. Answer B is correct.
The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in answers A, C, and D would require more chewing and, thus, are incorrect.
37. Answer A is correct.
Novalog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin. Answer B does not address a particular type of insulin, so it is incorrect. NPH insulin peaks in 8–12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer C. Answer D is incorrect because there is no need to save the dessert until bedtime.
38. Answer B is correct.
The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although answers A, C, and D might be important, they are not the primary answer to the question.
39. Answer D is correct.
Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative.
Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neu- trophils, or have a synergistic effect.
40. Answer A is correct.
The Hemophilus influenza vaccine is given at four months with the polio vaccine. Answers B, C, and D are incorrect because these vaccines are given later in life.
The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.
32. Answer A is correct.
The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simulta- neously, making answer C incorrect. The Tail of Spence (the upper outer quadrant of the breast) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect.
33. Answer B is correct.
Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.
34. Answer B is correct.
The best indicator of peripheral edema is measuring the extremi- ty. A paper tape measure should be used rather than one made of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment.
Answer A is incorrect because weighing the client will not indicate peripheral edema.
Answer C is incorrect because checking the intake and output will not indicate periph- eral edema.
Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.
35. Answer D is correct.
Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, put- ting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important.
Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.
36. Answer B is correct.
The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in answers A, C, and D would require more chewing and, thus, are incorrect.
37. Answer A is correct.
Novalog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin. Answer B does not address a particular type of insulin, so it is incorrect. NPH insulin peaks in 8–12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer C. Answer D is incorrect because there is no need to save the dessert until bedtime.
38. Answer B is correct.
The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although answers A, C, and D might be important, they are not the primary answer to the question.
39. Answer D is correct.
Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative.
Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neu- trophils, or have a synergistic effect.
40. Answer A is correct.
The Hemophilus influenza vaccine is given at four months with the polio vaccine. Answers B, C, and D are incorrect because these vaccines are given later in life.
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