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Questions 164

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Question 1 of 5

The 11:00 AM routine fingerstick (glucose monitoring) test for a client was assigned to the unlicensed assistive personnel by the nurse. At 11:15 AM, the client tells the nurse that no one checked the blood level. The nurse should take what action first?

Correct Answer: C

Rationale: Performing the test ensures timely glucose monitoring, which is critical for the client's care.

Question 2 of 5

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Exercise, lighting, handrails, and rounds reduce fall risk. Smooth-soled shoes increase slipping risk.

Question 3 of 5

The nurse monitoring a newborn after birth observes a bluish discoloration of the hands and feet. The trunk is pink. What is the nurse's initial action?

Correct Answer: D

Rationale: Acrocyanosis is normal in newborns. Skin-to-skin contact promotes thermoregulation and bonding.

Question 4 of 5

A woman who is pregnant for the first time asks the nurse when during pregnancy is the best time to take Lamaze classes. What should the nurse respond?

Correct Answer: B

Rationale: The second trimester is ideal for Lamaze classes, as it allows time to learn techniques before labor while avoiding early pregnancy discomforts and late-term fatigue.

Question 5 of 5

Which of the following signs is highly suggestive of impaired hearing in an infant?

Correct Answer: B

Rationale: Absence of babbling by 7 months is a red flag for hearing impairment, as infants typically begin vocalizing in response to sounds. Other signs are less specific to hearing.

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