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Questions 160

NCLEX-PN

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Extract:


Question 1 of 5

The nurse is preparing to administer a tuberculin skin test. Which site is most appropriate?

Correct Answer: A

Rationale: The inner forearm provides a clear, accessible site for reading the tuberculin skin test reaction.

Question 2 of 5

A pregnant client with known human immunodeficiency virus (HIV) infection is admitted to the hospital in active labor. Which method of fetal assessment is most appropriate?

Correct Answer: C

Rationale: External fetal monitoring is non-invasive, minimizing HIV transmission risk during labor compared to invasive methods.

Question 3 of 5

When monitoring the treatment response of a client with diabetes insipidus, which component of the urinalysis is most important for the nurse to assess?

Correct Answer: C

Rationale: Diabetes insipidus causes dilute urine with low specific gravity. Monitoring specific gravity assesses treatment effectiveness in restoring normal urine concentration.

Question 4 of 5

The female nurse is sitting across a table from the Latino male she has been educating about testicular self-examination. When the client successfully verbalizes the process, the nurse excitedly praises the client, leans over the table, and makes the "OK" sign with her thumb and forefinger. The client angrily gets up and abruptly leaves the room. What likely caused the client's abrupt departure?

Correct Answer: C

Rationale: A. Since the client had participated in the discussion up to the point of the nurse's actions, he obviously was not uncomfortable with the discussion. B. A Latino is usually not uncomfortable with close personal space; some Latinos perceive Anglos as distant because they prefer more personal space during a conversation. C. In much of Latin America, the North American "OK" sign (i.e., pinched thumb and forefinger) may be considered obscene. D. Anger and an abrupt departure are usually not behaviors displayed by the client when teaching is completed.

Question 5 of 5

A 17-year-old unmarried postpartum client is being discharged. Which situation suggests the need for a community-based assistance referral after discharge?

Correct Answer: B

Rationale: Living alone as a young, unmarried mother indicates a lack of immediate support, necessitating a referral for community assistance.

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