Strategy: Determine if the answer choice relates to Valium.

(1) more indicative of preoperative complications, and should be reported before

medications are given
(2) more indicative of preoperative complications, and should be reported before
medications are given
(3) correctobservation most indicative for antianxiety drugs is restlessness and
increase in heart rate due to circulating catecholamines (fight or flight)
(4) hostility may be best treated by ventilating feelings
80. A client with multiple sclerosis (MS) at 39-weeks gestation is admitted
to the labor and delivery unit in active labor. The clients vital signs are: BP
127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate
contractions are 4 minutes apart. The nurse should anticipate the need for
which of the following interventions?
1.
2.
3.
4.

Prepare to administer IV Pitocin to the client.

A reduction in the amount of pain medication administered.
Check the clients blood pressure every 5 minutes.
Prepare an isolette for the infant.

Strategy: Answers are a mix of assessments and implementations. Does the

assessment make sense? No. Determine the outcome of each intervention.
(1) uterine contractions not affected by MS
(2) correctless pain medication is required due to overall decrease in pain
perception due to MS
(3) no reason to assess this frequently
(4) babys outcome not affected by MS
81. The clinic nurse is performing diet teaching with a 67-year-old client
with acute gout. The nurse should teach the client to limit his intake of
1.
2.
3.
4.

red meat and shellfish.

cottage cheese and ice cream.
fruit juices and milk.
fresh fruits and uncooked vegetables.

Strategy: Answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) correctshould be on low-purine diet, should avoid red and organ meats,
shellfish, oily fish with bones
(2) calcium-rich foods are not limited with gout
(3) no restriction with gout
(4) high-roughage foods are not limited with gout
82. When assisting with a bone marrow aspiration, the nurse should
1.
2.
3.
4.

drop additional sterile supplies onto a sterile tray.

have all sterile packs unwrapped for the procedure in case they are needed.
reach over the tray and remove contaminated supplies.
place the bottle of sterile liquid on the sterile field so it does not splash.