Strategy: Determine the outcome of each answer choice. Is it desired?

(1) correctaspirin can cause fetal hemorrhage, do not use during pregnancy
(2) routine follow-up
(3) treat sprain with rest and elevation of affected part; intermittent ice compresses
for 24 hours
(4) appropriate gait if client unable to bear weight
143. Which of the following nursing actions would be important for safe
administration of oxytocin?
1.
2.
3.
4.

Assess respirations and urine output.

Administer oxytocin parenterally as the primary IV.
Have calcium gluconate available as an antidote.
Palpate the uterus frequently.

Strategy: Answers are a mix of assessments and implementations. Is there

an appropriate assessment? Yes.
(1) assessment, pertinent to the care of a client receiving magnesium sulfate for
preeclampsia
(2) implementation, oxytocin is always given via an infusion pump and is never
allowed to be the primary IV
(3) implementation, pertinent to the care of a client receiving magnesium sulfate for
preeclampsia
(4) correctassessment, oxytocin stimulates the uterus to contract, which
necessitates frequent assessment of the uterus; prolonged tetanic contraction can
lead to a ruptured uterus
144. An adult client has regular insulin ordered before breakfast. The nurse
notes that the clients blood glucose level is 68 mg/dL, and the client is
nauseated. Which of the following actions should the nurse take?
1.
2.
3.
4.

Immediately give the client orange juice to drink.

Administer the insulin on time.
Withhold the insulin and notify the physician.
Return the breakfast tray to the kitchen.

Strategy: All answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) may cause vomiting
(2) correcttake insulin or oral agent as ordered, check blood glucose or urine
ketones every 3-4
hours, sip 8-12 oz liquid per hour, substitute easily digested soft foods, liquids if
solids not tolerated
(3) blood glucose increases during illness even though client cant eat, administer
insulin
(4) does not address the clients problem