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Questions 160

NCLEX-PN

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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

The client with waits in the labial area is being seen in the clinic. The client is tearful and states to the nurse, "I'm so embarrassed that I let this happen to me." Which response by the nurse is appropriate?

Correct Answer: C

Rationale: A. This response dismisses the client's feelings of embarrassment over an STI. B. This response dismisses the client's feelings and promotes client dependency. It does not allow for further exploration of feelings. C. This response is appropriate because it acknowledges the client's feelings. It provides brief information and then time for the client to express thoughts regarding the situation. D. This response dismisses the client's feelings.

Question 3 of 5

A client with a history of chronic lymphocytic leukemia is at risk for infection. Which nursing intervention is most appropriate?

Correct Answer: A

Rationale: Frequent handwashing reduces infection risk in immunocompromised clients.

Question 4 of 5

Laboratory data for an adult client diagnosed with Pneumocystis carinii pneumonia indicate immunosuppression. Which is the most important in determining the client's susceptibility to this infection?

Correct Answer: D

Rationale: Pneumocystis carinii pneumonia is associated with immunosuppression, often linked to HIV, which is commonly transmitted through sexual practices.

Question 5 of 5

The client, who had been prescribed sildenafil 2 weeks ago for erectile dysfunction, calls the clinic to report that nothing happens, despite taking sildenafil orally and waiting for his erection to develop. Which fact should the nurse consider before responding to the client?

Correct Answer: C

Rationale: A. In clinical trials, some improvement in erectile hardness and duration was reported by 70% of men taking sildenafil. B. Sildenafil should be taken orally. C. Sildenafil (Viagra) enhances the normal erectile response to sexual stimuli by promoting relaxation of arterial and trabecular smooth muscle. The resultant arterial dilation causes engorgement of sinusoidal spaces in the corpus cavernosum. In the absence of sexual stimuli, however, nothing will happen. D. A fatty meal delays absorption, and, as a result, plasma levels peak in 2 hours instead of an hour; it does not cause sildenafil to be ineffective.

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