A client reports weakness, dizziness, nausea and vomiting that has lasted for three days. The nurse's assessment reveals dry tongue and oral mucosa, and dark concentrated urine. Which additional assessment would best evaluate the client's fluid status?

Respiratory rate and depth

Rectal temperature

Blood pressure lying, sitting and standing

Pulse oximetry reading at rest

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not the best answer. Respiratory rate and depth can indicate the client's oxygenation and ventilation, but not necessarily their fluid status. The client may have normal or increased respiratory rate and depth due to dehydration, acidosis, or anxiety, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's respiratory rate and depth, but also assess other parameters of fluid status.

Choice B reason: This is not the best answer. Rectal temperature can indicate the client's core body temperature, but not necessarily their fluid status. The client may have normal or elevated rectal temperature due to infection, inflammation, or dehydration, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's rectal temperature, but also assess other parameters of fluid status.

Choice C reason: This is the best answer. Blood pressure lying, sitting and standing can indicate the client's fluid status and vascular tone. The client may have low blood pressure due to fluid loss, hypovolemia, or vasodilation, and this can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. The nurse should measure the client's blood pressure in different positions and observe for signs of orthostatic hypotension, such as dizziness, fainting, or blurred vision.

Choice D reason: This is not the best answer. Pulse oximetry reading at rest can indicate the client's oxygen saturation, but not necessarily their fluid status. The client may have normal or decreased pulse oximetry reading due to hypoxia, anemia, or poor peripheral perfusion, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's pulse oximetry reading, but also assess other parameters of fluid status.

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Correct Answer is C

Explanation

Choice A reason: Stopping the medication if the client develops a change in vision is not the information that the nurse should provide in the teaching about rosuvastatin. Rosuvastatin is a drug that lowers the cholesterol and prevents the complications of cardiovascular disease. It belongs to a class of drugs called statins, which work by inhibiting an enzyme that produces cholesterol in the liver. Change in vision is not a common or serious side effect of rosuvastatin, and it may be caused by other factors, such as eye strain, infection, or disease. The nurse should not advise the client to stop the medication without consulting the healthcare provider, as this may increase the risk of adverse outcomes, such as heart attack or stroke.

Choice B reason: Monitoring body weight weekly is not the information that the nurse should provide in the teaching about rosuvastatin. Rosuvastatin is a drug that lowers the cholesterol and prevents the complications of cardiovascular disease. It belongs to a class of drugs called statins, which work by inhibiting an enzyme that produces cholesterol in the liver. Body weight is not a direct indicator of the effectiveness or safety of rosuvastatin, and it may fluctuate due to various factors, such as diet, exercise, or fluid retention. The nurse should encourage the client to maintain a healthy weight and lifestyle, but not to focus on the weekly changes in body weight.

Choice C reason: Reporting muscle weakness or pain is the information that the nurse should provide in the teaching about rosuvastatin. Rosuvastatin is a drug that lowers the cholesterol and prevents the complications of cardiovascular disease. It belongs to a class of drugs called statins, which work by inhibiting an enzyme that produces cholesterol in the liver. However, statins can also cause muscle damage, which can manifest as weakness, pain, tenderness, or cramps. This can be a sign of a serious condition called rhabdomyolysis, which is the breakdown of muscle tissue that can lead to kidney failure or death. The nurse should instruct the client to report any muscle symptoms to the healthcare provider as soon as possible, and to avoid taking any other drugs or supplements that may interact with rosuvastatin and increase the risk of muscle damage.

Choice D reason: Having biannual renal function studies is not the information that the nurse should provide in the teaching about rosuvastatin. Rosuvastatin is a drug that lowers the cholesterol and prevents the complications of cardiovascular disease. It belongs to a class of drugs called statins, which work by inhibiting an enzyme that produces cholesterol in the liver. Renal function studies are tests that measure the health and function of the kidneys, which are responsible for filtering the blood and removing waste and excess fluid. Rosuvastatin is not known to cause significant kidney damage, and it is excreted mainly by the liver. The nurse should not recommend the client to have biannual renal function studies, as this may be unnecessary and costly. The nurse should advise the client to follow the healthcare provider's orders regarding the frequency and type of laboratory tests that are needed to monitor the effects of rosuvastatin.

A. Cholesterol 200 mg/dL; HDL 35 mg/dL; triglycerides 190 mg/dL B. Cholesterol 120 mg/dL; HDL 50 mg/dL; triglycerides 140 mg/dL C. Cholesterol 180 mg/dL; HDL 40 mg/dL; triglycerides 220 mg/dL D. Cholesterol 165 mg/dL; HDL 54 mg/dL; triglycerides 160 mg/dL

Correct Answer is C

Explanation

Choice A reason: This option is not correct because the cholesterol level is within the normal range of less than 200 mg/dL¹, the HDL level is slightly low but not too far from the recommended level of over 40 mg/dL for men and over 50 mg/dL for women¹, and the triglyceride level is also within the normal range of less than 150 mg/dL¹. Therefore, this set of laboratory results does not indicate a need for dietary modifications.

Choice B reason: This option is not correct because the cholesterol level is low, the HDL level is high, and the triglyceride level is normal. These are all desirable results that reflect a low risk of coronary artery disease¹. Therefore, this set of laboratory results does not indicate a need for dietary modifications.

Choice C reason: This option is correct because the cholesterol level is high, the HDL level is low, and the triglyceride level is high. These are all unfavorable results that reflect a high risk of coronary artery disease¹. High cholesterol and triglycerides can lead to plaque buildup in the arteries, which can cause atherosclerosis and reduce blood flow to the heart². Low HDL can also increase the risk of heart disease because it does not help remove LDL (bad cholesterol) from the arteries². Therefore, this set of laboratory results indicates a need for dietary modifications, such as reducing saturated and trans fats, increasing fiber, and limiting alcohol³.

Choice D reason: This option is not correct because the cholesterol level is normal, the HDL level is high, and the triglyceride level is normal. These are all desirable results that reflect a low risk of coronary artery disease¹. Therefore, this set of laboratory results does not indicate a need for dietary modifications..

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A client reports weakness, dizziness, nausea and vomiting that has lasted for three days. The nurse's assessment reveals dry tongue and oral mucosa, and dark concentrated urine. Which additional assessment would best evaluate the client's fluid status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is prescribed rosuvastatin 10 mg PO daily. What information will the nurse provide in the teaching about this medication?

Correct Answer is C

Explanation

The nurse is reviewing the laboratory data of a client diagnosed with coronary artery disease. Which set of laboratory results indicates a need for client teaching regarding dietary modifications?

Correct Answer is C

Explanation

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