NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Mr. and Mrs. K have just adopted a newborn infant and are preparing to take him home from the hospital for the first time. Which safety measure is most appropriate for the clients in this situation?
- A. Turn the handles of pans on the stove inward
- B. Set up a baby gate at the top of the stairs
- C. Cover electrical outlets with child-proof plugs
- D. Install an approved car seat that is facing backward in the back seat
Correct answer: D
Rationale: Parents of newborn infants should use an approved car seat that has been installed facing backward in the back seat of the car. Securing infants in car seats, even from the first ride home from the hospital, promotes safety while transporting. While safety measures at home such as baby gates or outlet covers are important, they are not the priority safety measures until the baby is old enough to be mobile. The car seat is crucial for protecting the newborn during transportation, ensuring proper positioning and restraint in the event of sudden stops or accidents. Turning handles of pans on the stove inward, setting up a baby gate, and covering electrical outlets are important safety measures at home but are not as critical for the immediate safety of a newborn during transportation.
2. 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.
3. When percussing over the abdomen of an obese patient, the nurse is unable to identify any changes in sound. What would the nurse do next?
- A. Ask the patient to take deep breaths to relax the abdominal musculature.
- B. Consider this finding as normal and proceed with the abdominal assessment.
- C. Increase the amount of strength used when attempting to percuss over the abdomen.
- D. Decrease the amount of strength used when attempting to percuss over the abdomen.
Correct answer: C
Rationale: When percussing an obese patient's abdomen, the thickness of their body wall can affect the sound produced. A stronger percussion stroke is needed for obese or very muscular patients. The force of the blow determines the loudness of the note. Asking the patient to take deep breaths, considering the finding as normal, or decreasing the strength used are not appropriate actions in this scenario.
4. Digestion, elimination, and ___________ are the three functions of the digestive system.
- A. constriction
- B. relaxation
- C. absorption
- D. peristalsis
Correct answer: C
Rationale: The correct answer is 'absorption.' The three main functions of the digestive system are digestion, absorption, and elimination. Absorption refers to the process of absorbing nutrients and other substances from the digested food into the bloodstream. Choices A, B, and D are incorrect: Constriction is not a primary function of the digestive system, relaxation is not a distinct function in this context, and peristalsis is a muscular movement that aids in digestion but is not one of the three main functions of the digestive system.
5. 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.
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