NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. Where is the Loop of Henle located in the body?
- A. Liver
- B. Kidney
- C. Heart
- D. Ear
Correct answer: B
Rationale: The Loop of Henle is a crucial structure found in the kidneys. It plays a vital role in the concentration of urine by creating a concentration gradient in the renal medulla. Choices A, C, and D are incorrect because the Loop of Henle is not located in the liver, heart, or ear. Understanding the anatomical location of the Loop of Henle is essential in comprehending renal physiology and the mechanism of action of diuretic medications.
2. When a patient refuses to believe a terminal diagnosis, they are exhibiting:
- A. Regression
- B. Mourning
- C. Denial
- D. Rationalization
Correct answer: C
Rationale: Denial is a defense mechanism where a patient rejects a reality that is too painful or difficult to accept. In the context of a terminal diagnosis, the patient may refuse to believe it in order to avoid facing the harsh truth. Regression (choice A) involves reverting to earlier, more childlike behaviors and is not applicable in this scenario. Mourning (choice B) is the process of grieving a loss, which typically occurs after acceptance of the diagnosis. Rationalization (choice D) is creating logical explanations to justify unacceptable behaviors, which is not the case when a patient denies a terminal diagnosis.
3. During an examination, a nurse notices a draining ulceration on a patient's lower leg. What is the most appropriate action in this situation?
- A. Wash hands and then contact the physician.
- B. Continue to examine the ulceration and then wash hands.
- C. Wash hands, put on gloves, and continue with the examination of the ulceration.
- D. Wash hands, proceed with the rest of the physical examination, and perform the examination of the leg ulceration last.
Correct answer: C
Rationale: In this scenario, the most appropriate action is to wash hands, put on gloves, and then continue examining the ulceration. Wearing gloves is crucial when there is a possibility of contact with body fluids, as in the case of a draining ulceration. Contacting the physician is not necessary at this point; the immediate focus should be on proper infection control by washing hands and wearing gloves. Changing the order of the examination is not recommended as it is important to follow a systematic approach to avoid missing any crucial assessments.
4. A client has just started a transfusion of packed red blood cells that a physician ordered. Which of the following signs may indicate a transfusion reaction?
- A. The client suddenly complains of back pain and has chills
- B. The client develops dependent edema in the extremities
- C. The client has a seizure
- D. The client's heart rate drops to 60 bpm
Correct answer: A
Rationale: The correct answer is when the client suddenly complains of back pain and has chills. Signs of a transfusion reaction include back pain, chills, dizziness, increased temperature, and blood in the urine. These signs indicate a possible adverse reaction to the blood transfusion. Dependent edema in the extremities is not typically associated with a transfusion reaction. A seizure is not a common sign of a transfusion reaction unless it is due to severe complications. A decrease in heart rate to 60 bpm is not a typical sign of a transfusion reaction, but rather bradycardia may indicate other underlying conditions or medications.
5. 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.
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