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Questions 149

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Question 1 of 5

A nurse has delegated care of a client in wrist restraints to a nursing assistant. The nursing assistant should check the skin circulation under the restraints at least

Correct Answer: C

Rationale: Restraints require circulation checks every 1-2 hours to prevent skin breakdown or neurovascular injury. Hourly checks (
C) balance safety and practicality.

Question 2 of 5

A client has been diagnosed with immune thrombocytic purpura (ITP). Which of the following signs and symptoms indicate increased thrombocytopenia? Select all that apply.

Correct Answer: A,B

Rationale: ITP causes low platelets, leading to nosebleeds (
A) and petechiae/bruising (
B). Vision changes (
C), numbness (
D), and confusion (E) are not typical.

Question 3 of 5

The nurse is teaching a client with a new diagnosis of glaucoma about eye drop administration. Which of the following instructions should the nurse include?

Correct Answer: A

Rationale: applying pressure to the inner canthus (nasolacrimal occlusion) prevents systemic absorption of the medication

Question 4 of 5

An obstetrical client with diabetes has an amniocentesis at 28 weeks gestation. Which test indicates the degree of fetal lung maturity?

Correct Answer: D

Rationale: The lecithin-sphingomyelin (L/S) ratio assesses fetal lung maturity by measuring surfactant levels, critical for preterm delivery planning in diabetic pregnancies.

Question 5 of 5

The client with color blindness will most likely have problems distinguishing which of the following colors?

Correct Answer: C

Rationale: Red-green color blindness is the most common type, making it difficult to distinguish red.

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