NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. One of your patients is dependent on a mechanical ventilator for their respiratory needs. The patient cannot breathe on their own. Suddenly, the lights in the patient's room and the entire nursing unit go off. You realize that the electric power has been lost. What is the first thing that you should do for this patient?
- A. Plug the ventilator into the red outlet in the room.
- B. Plug the ventilator into the blue outlet in the room.
- C. Use an Ambu bag to ventilate the patient.
- D. Call the doctor about this emergency.
Correct answer: B
Rationale: In healthcare facilities, emergency generators are in place in case of power outages. The red outlets in patient rooms are connected to the emergency generator and provide power during such situations. By plugging the ventilator into the red outlet, you ensure that the patient's mechanical ventilation needs are met despite the power loss. Using an Ambu bag or calling the doctor should be secondary actions after ensuring the ventilator is powered correctly. Plugging the ventilator into the blue outlet is incorrect and can result in the ventilator not functioning during a power outage.
2. What does the term 'Afferent Nerve' mean?
- A. Carrying an impulse to the brain
- B. Carrying an impulse away from the brain
- C. Carrying impulses to the motor neurons of the appendicular muscles
- D. None of the above
Correct answer: A
Rationale: The correct answer is 'Carrying an impulse to the brain.' Afferent nerves are sensory nerves that carry signals from sensory receptors towards the central nervous system, including the brain. Choice B, 'Carrying an impulse away from the brain,' is incorrect as this describes efferent nerves which carry signals from the central nervous system to muscles and glands. Choice C, 'Carrying impulses to the motor neurons of the appendicular muscles,' is incorrect as it describes a different type of nerve function. Choice D, 'None of the above,' is incorrect as the correct definition of afferent nerve is indeed 'Carrying an impulse to the brain.'
3. Which of the following puts the layers of skin in the correct order from right to left?
- A. Dermis, epidermis, hypodermis
- B. Hypodermis, epidermis, dermis
- C. Epidermis, dermis, hypodermis
- D. None of the above
Correct answer: C
Rationale: The correct order of the layers of skin from outermost to innermost is the epidermis, dermis, and then the hypodermis. The epidermis is the outermost layer of the skin, followed by the dermis, which is the middle layer containing connective tissue, hair follicles, and sweat glands. The hypodermis, also known as the subcutaneous tissue, lies beneath the dermis and consists of fat and connective tissue. Choice A is incorrect as it lists the layers in the reverse order. Choice B is incorrect as it reverses the order of the layers. Choice D is incorrect as there is a correct answer among the choices.
4. A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent?
- A. Relex incontinence
- B. Urge incontinence
- C. Total incontinence
- D. Functional incontinence
Correct answer: D
Rationale: Functional incontinence occurs when a client develops an urge to void but may not be able to reach the toilet in time. In this scenario, the client had the urge to use the restroom but was unable to make it in time, leading to incontinence. Functional incontinence may be related to conditions that cause the client to forget bladder sensation until the last minute, such as cognitive changes, or the client may have mobility problems that prevent her from reaching the bathroom in time. Choice A, Reflex incontinence, is incorrect as reflex incontinence is characterized by the involuntary loss of urine due to hyperreflexia of the detrusor muscle. Choice B, Urge incontinence, is not the correct answer as urge incontinence is the involuntary loss of urine associated with a strong desire to void. Choice C, Total incontinence, is also incorrect as it refers to the continuous and unpredictable loss of urine, not specifically related to the inability to reach the toilet in time.
5. Patients who cannot move in their bed on their own should be turned at least ________________.
- A. once a day
- B. twice a day
- C. every 2 hours
- D. every 4 hours
Correct answer: C
Rationale: Patients who are unable to move in bed are at high risk of developing pressure ulcers and skin breakdown due to prolonged pressure on specific body areas. Turning these patients at least every 2 hours is crucial to relieve pressure, improve circulation, and prevent skin damage. More frequent turning may be necessary for patients with specific needs, such as those who are incontinent of urine and require additional care. Turning patients less frequently, such as once a day, twice a day, or every 4 hours, increases the risk of developing pressure ulcers and other complications. Therefore, the correct answer is to turn patients who cannot move in their bed on their own every 2 hours.
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