The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse assesses that the amniotic fluid is normal if it has which of the following characteristics?
1. Clear and dark amber color
2. Light green color with no odor
3. Thick white color with no odor
4. Straw-colored, with flecks of vernix
4
Rationale: Amniotic fluid is normally a pale straw color and may contain flecks of vernix case-osa. It should have a thin watery consistency and may have a mild odor. The other options are not descriptions of normal amniotic fluid.
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The nurse is taking the history of a psychiatric client suspected of abusing alcohol. Which assessment question is best to ask?
1. When was your last drink? 2. Do you drink regularly? 3. Are you experiencing blackouts? 4. Who are your drinking partners?
After achieving magnet status, a nurse manager asks the Director of Nursing, "How often are the site visits for the re-designation of magnet status for organizations?" The most appropriate response from the Director would be which of the
following? a. 2 years c. 4 years b. 3 years d. 5 years
Patients who use inhalants and hallucinogens are likely to experience which negative effects? (Select all that apply.)
a. Distortion of senses b. Intense pruritus c. Uncontrolled flashbacks d. Koilonychia e. Severely impaired judgment
You are the rehabilitation nurse caring for a 25-year-old patient who suffered extensive injuries in a motorcycle accident. During each patient contact, what action should you perform most frequently?
A) Complete a physical assessment. B) Evaluate the patient's positioning. C) Plan nursing interventions. D) Assist the patient to ambulate.