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Extract:


Question 1 of 5

A client's vision is to be evaluated using the Ishihara exam. The nurse recognizes that the client will be checked for:

Correct Answer: C

Rationale: The Ishihara exam tests for color blindness by assessing color perception. It does not evaluate macular degeneration, astigmatism, or glaucoma.

Question 2 of 5

The nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following findings would indicate a complication of TPN therapy?

Correct Answer: B

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia, a common TPN complication due to high dextrose content, requiring insulin adjustment or rate change. Weight gain (
A) is expected, low-grade fever (
C) is nonspecific, and normal urine output (
D) is unremarkable.

Extract:

Thirty minutes after delivery the nurse finds that a mother's uterus is relaxed and the lochia is excessive.


Question 3 of 5

The fist action by the nurse should be to:

Correct Answer: D

Rationale: Massaging the uterus promotes contraction, reducing excessive lochia and preventing hemorrhage.

Extract:


Question 4 of 5

A newborn is to receive phototherapy for hyperbilirubinemia. Which nursing action is essential?

Correct Answer: D

Rationale: Covering the eyes protects the newborn's retinas from phototherapy light, a critical safety measure.

Question 5 of 5

A nurse is caring for a pregnant patient in her third trimester. Which of the following findings should be reported immediately?

Correct Answer: C

Rationale: Severe headache and visual disturbances suggest preeclampsia, a medical emergency. Mild edema, heartburn, and frequent urination are normal in late pregnancy.

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