NCLEX 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: Kidney
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. All of the following factors may contribute to client falls EXCEPT:
- A. Contact dermatitis
- B. Urinary frequency
- C. Decreased visual acuity
- D. Confusion
Correct answer: Contact dermatitis
Rationale: Client falls can result from various factors, both intrinsic and extrinsic. Intrinsic factors include health conditions like urinary frequency, which increases the need for bathroom visits, decreased visual acuity, and confusion. These factors can directly contribute to an increased risk of falls. However, contact dermatitis does not directly lead to falls. Contact dermatitis is a skin condition caused by contact with irritants or allergens and does not inherently predispose individuals to falling. Therefore, among the given options, contact dermatitis is the only factor that is not directly associated with an increased risk of falls.
3. A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom?
- A. Haloperidol (Haldol) to address the negative symptom
- B. Clonazepam (Klonopin) to address the positive symptom
- C. Risperidone (Risperdal) to address the positive symptom
- D. Clozapine (Clozaril) to address the negative symptom
Correct answer: Risperidone (Risperdal) to address the positive symptom
Rationale: The correct medication to address the symptom described, where the client is slow to respond and appears to be listening to unseen others, is Risperidone (Risperdal). Risperidone is an atypical antipsychotic that is commonly used to manage positive symptoms of schizophrenia. Positive symptoms can include hallucinations, delusions, and disorganized thinking. Haloperidol (Haldol) and Clozapine (Clozaril) are typically used for addressing negative symptoms, such as lack of motivation or social withdrawal. Clonazepam (Klonopin) is a benzodiazepine primarily used for anxiety disorders and seizures, not for addressing symptoms of schizophrenia.
4. When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
- A. Securely grasp the client's arm and leg.
- B. Put bed rails up on the side of bed opposite from the nurse.
- C. Correctly position and use a turn sheet.
- D. Lower the head of the client's bed slowly
Correct answer: Put bed rails up on the side of bed opposite from the nurse.
Rationale: When turning an immobile bedridden client without assistance, the best action to ensure client safety is to put bed rails up on the side of the bed opposite from the nurse. This is important because the nurse can only stand on one side of the bed, so having bed rails on the opposite side prevents the client from falling out of bed. Option A, which suggests securely grasping the client's arm and leg, can potentially cause client injury to the skin or joints. Options C and D, correctly positioning and using a turn sheet, and lowering the head of the client's bed slowly, respectively, are useful techniques during client turning but are of lower priority in terms of safety compared to the use of bed rails.
5. What is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn?
- A. Encouraging the father to participate in a parenting class
- B. Providing time for the father to be alone with and get to know the baby
- C. Offering the father a demonstration on newborn diapering, feeding, and bathing
- D. Allowing time for the father to ask questions after viewing a film about a new baby
Correct answer: Providing time for the father to be alone with and get to know the baby
Rationale: The priority nursing action to assist an anxious father in his concern about not bonding with his newborn is providing time for the father to be alone with and get to know the baby. Time alone provides the opportunity for paternal-infant attachment and bonding, which can help reduce the father's anxiety. Encouraging the father to participate in a parenting class, although helpful, does not directly address the immediate need for bonding. Offering a demonstration on newborn care tasks like diapering, feeding, and bathing may not effectively address the father's anxiety at that moment, as he may not be ready to absorb such information. Allowing time for the father to ask questions after viewing a film about a new baby is a simplistic approach that may not adequately address the emotional needs and concerns of the father regarding bonding with his newborn.
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