Strategy: Answers are a mix of assessments and implementations.

Does this
situation require assessment? Yes. Is there an appropriate assessment?
Yes.
(1) correctassessment, symptoms indicate reduced oxygen levels
(2) implementation, must assess first to determine problem; all other interventions
must be tried before using restraints
(3) implementation, must determine the cause of the behavior before implementing
(4) assessment, symptoms indicate decreased oxygen levels
140. To maintain client safety, the nurse should have which of the following
equipment readily available when inserting an Ewald tube?
1.
2.
3.
4.

Suction equipment.
Blood pressure cuff.
Levine tube.
Emesis basin.

Strategy: Think about each answer choice.

(1) correctEwald tube is a large orogastric tube designed for rapid lavage; insertion
often causes gagging and vomiting, suction equipment must be immediately
available to reduce the risk of aspiration
(2) not a high priority
(3) not a high priority
(4) not a high priority
141. In planning anticipatory guidance for parents of a beginning schoolaged child, it is MOST important for the nurse to include which of the
following?
1.
2.
3.
4.

Teach the child to read and write.

Teach the child sex education at home.
Give the child responsibility around the house.
Expect stormy behavior.

Strategy: Answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) may require some assistance from the parents, but children this age learn at
their own rate
(2) unnecessary at this early age
(3) correctgiving children responsibilities allows them to develop feelings of
competence and selfesteem through their industry
(4) does not occur until about age 11
142. The nurse is caring for clients in the antepartal clinic. A client at 34weeks gestation comes to the clinic for treatment of a sprained ankle. The
nurse should question which of the following orders?
1.
2.
3.
4.

ASA (aspirin) 650 mg PO q4h PRN for pain.

Return to the clinic in two weeks.
Ice to sprain for 20 minutes qh for 24h.
Teach client 3-gait crutch walking.