Nokea
A nurse smells an odor identified as marijuana coming from a room. Which of the following client findings would confirm inhalation of the substance?
- A. Poor coordination, red eyes, and euphoria
- B. Slurred speech, confusion, and combativeness
- C. Loss of consciousness, respiratory depression, and coma
- D. Hypertension, tachycardia, and hyperflexia
Correct Answer: A
Rationale: The correct answer is A because poor coordination, red eyes, and euphoria are classic signs of marijuana inhalation. Poor coordination is a common effect due to impairment of motor skills. Red eyes result from vasodilation caused by marijuana. Euphoria is a psychological effect of the drug. Slurred speech, confusion, and combativeness (Option B) are more indicative of alcohol or sedative use. Loss of consciousness, respiratory depression, and coma (Option C) are severe symptoms more likely associated with opioid or sedative overdose. Hypertension, tachycardia, and hyperflexia (Option D) are not typically seen with marijuana use; they are more consistent with stimulant use.
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The physician performs an amniotomy for a woman in labor. Which nursing action should follow the procedure?
- A. Check the client's capillary refill and oxygenation.
- B. Monitor the maternal pulse and blood pressure.
- C. Inspect the perineum for lacerations, bleeding, and hematoma.
- D. Assess the fluid for color, odor, and amount.
Correct Answer: D
Rationale: The correct answer is D: Assess the fluid for color, odor, and amount. After an amniotomy, it is important to assess the amniotic fluid to ensure it is clear, odorless, and of the appropriate amount, as changes in these characteristics may indicate fetal distress or infection. Checking capillary refill and oxygenation (Choice A) is not directly related to an amniotomy. Monitoring maternal pulse and blood pressure (Choice B) is important but not the immediate priority post-amniotomy. Inspecting the perineum for lacerations, bleeding, and hematoma (Choice C) is important for overall assessment but not specific to the procedure.
A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client demonstrates understanding of the instructions, stating she will notify the physician if which sign occurs?
- A. White vaginal discharge
- B. Dull backache
- C. Frequent,urgent urination
- D. Abdominal pain
Correct Answer: D
Rationale: The correct answer is D: Abdominal pain. Abdominal pain is a significant danger sign in pregnancy that could indicate various complications such as ectopic pregnancy, placental abruption, or preterm labor. Prompt medical evaluation is crucial to ensure the health of both the mother and the baby. White vaginal discharge (A) is not necessarily a danger sign unless it is accompanied by other symptoms like itching or a foul smell. Dull backache (B) is common in pregnancy and usually not a cause for concern unless severe or accompanied by other symptoms. Frequent, urgent urination (C) is a common symptom in pregnancy due to increased pressure on the bladder and is not typically a danger sign unless associated with pain or burning.
An 8-year-old child is admitted to a pediatric unit with a fractured femur and is placed in skeletal traction. Which of the following nursing interventions is the most appropriate?
- A. Position the weights securely against the foot of the bed.
- B. Provide small frequent high-fat meals to the child.
- C. Compare pulses on affected site to contralateral side.
- D. Provide diversional activities to minimize the child's movement.
Correct Answer: C
Rationale: The correct answer is C: Compare pulses on affected site to contralateral side. This is the most appropriate nursing intervention because it assesses for any circulatory compromise due to the skeletal traction. Checking pulses helps monitor perfusion distal to the fracture site and ensures early detection of any complications like compartment syndrome. Positioning the weights against the foot of the bed (A) is incorrect as it can cause uneven traction. Providing high-fat meals (B) and diversional activities (D) are irrelevant to the immediate care of the child's fracture.
A 17-year-old client delivered her first baby 8 hours ago. Which of the following is an indication that appropriate bonding is occurring? The client:
- A. makes eye contact with the baby.
- B. wonders why the baby cries so much.
- C. asks the nurse to help change the baby's diaper.
- D. asks the nurse if the baby is cute.
Correct Answer: A
Rationale: The correct answer is A: makes eye contact with the baby. This indicates appropriate bonding as eye contact fosters emotional connection and attachment between mother and baby. It shows the mother is engaging with her child, seeking to establish a bond. Choice B suggests lack of understanding of infant communication, choice C indicates practical caregiving rather than emotional bonding, and choice D focuses on the baby's appearance rather than emotional connection.
At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally with her baby. Which response by the nurse is correct?
- A. The skin is wrinkled and fat is being formed.
- B. The eyelids are open and he can see.
- C. The kidneys are making urine.
- D. The heart is being developed.
Correct Answer: C
Rationale: Correct Answer: C - The kidneys are making urine.
Rationale: At 10 weeks gestation, the kidneys of the developing fetus begin to form and function, producing urine. This is a crucial milestone in fetal development as it indicates proper organ formation and functionality. The formation of urine by the kidneys plays a significant role in maintaining the amniotic fluid levels and supporting overall fetal growth and development.
Summary of other choices:
A: The skin is wrinkled and fat is being formed - Incorrect. Skin and fat formation typically occur later in gestation, not at 10 weeks.
B: The eyelids are open and he can see - Incorrect. Eye development is still in progress at 10 weeks, and the eyelids remain fused.
D: The heart is being developed - Incorrect. While the heart is forming at 10 weeks, it is not the most accurate response to the question posed by the primigravida.