Nokea
What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?
- A. Human chorionic gonadotropin
- B. Estrogen
- C. α-fetoprotein
- D. Sphingomyelin
Correct Answer: A
Rationale: Human chorionic gonadotropin is the biochemical basis for pregnancy tests, produced by the placenta to maintain the corpus luteum.
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The nurse is teaching basic newborn care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:
- A. New parents need time to learn how to hold the newborn.
- B. The umbilical cord needs time to separate.
- C. Newborn skin is easily traumatized by washing.
- D. The chance of chilling the newborn outweighs the benefits of bathing.
Correct Answer: B
Rationale: Sponge baths are recommended until the umbilical cord separates (typically within 1-2 weeks) to keep the cord dry and prevent infection. The other reasons are not the primary rationale for this practice.
The nurse is teaching the client with hepatitis B regarding transmission. The nurse should instruct the client to do which of the following?
- A. Refrain from eating fresh fruits and vegetables.
- B. Avoid using another family member's toothbrush.
- C. Clean the commode after each bowel movement.
- D. Boil water prior to drinking and place open containers in the refrigerator.
- E. Inform the dentist of his diagnosis.
Correct Answer: B, E
Rationale: Hepatitis B is transmitted via blood and bodily fluids. Avoiding sharing toothbrushes (B) prevents transmission through saliva or blood. Informing the dentist (E) ensures precautions during procedures. Eating fresh produce (A), cleaning the commode (C), and boiling water (D) are unrelated to hepatitis B transmission.
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
- A. Uses an electric blanket at night
- B. Dresses in extra layers of clothing
- C. Applies a heating pad to her feet
- D. Takes a hot bath morning and evening
Correct Answer: B
Rationale: Dressing in extra layers is a safe, effective way to manage cold intolerance in hypothyroidism by conserving body heat. Electric blankets and heating pads pose burn risks, and baths are temporary.
Goal setting for a client with Meniere's disease should include which of the following?
- A. Frequent ambulation
- B. Prevention of a fall injury
- C. Consumption of three meals per day
- D. Prevention of infection
Correct Answer: B
Rationale: Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. Vertigo resulting in balance problems is one of the most common manifestations of Meniere's disease. Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium. Infection is not an anticipated problem.
Which task should be delegated to the licensed practical nurse?
- A. Administering heparin subcutaneously
- B. Feeding the client with a percutaneous endoscopy gastrostomy tube
- C. Removing a peripherally inserted central line
- D. Monitoring chest tube drainage
- E. Performing tracheostomy care
Correct Answer: A, B, D, E
Rationale: LPNs can administer subcutaneous heparin (A), feed via PEG tube (B), monitor chest tubes (D), and perform tracheostomy care (E). Removing a PICC line (C) requires RN-level expertise due to potential complications.