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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 5 )

Updated On: 12-Jan-2026
Page 5 of 345
PDF with 862 Questions

Assessment of a newborn for Apgar scoring includes observation for:

  1. Pupil response
  2. Respiratory rate
  3. Heart rate
  4. Babinski's reflex

Answer(s): C

Explanation:

(A) Pupil response should be assessed but is not part of Apgar scoring. (B) Respiratory effort is an essential part of Apgar scoring, not respiratory rate. (C) Heart rate is the most critical component of Apgar scoring. (D) Assessment of Babinski's reflex is not a component of Apgar scoring.



A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:

  1. Gavage tube
  2. Nipple and bottle
  3. A straw and cup
  4. Syringe

Answer(s): D

Explanation:

(A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3-month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This
minimizes the amount of sucking needed.



A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

  1. Head of bed elevated 30 degrees on nonoperative side
  2. Head of bed elevated 30 degrees on operative side
  3. Bed flat on operative side
  4. Bed flat on nonoperative side

Answer(s): D

Explanation:

(A) Elevation of head on nonoperative side would be the position for the late postoperative period. (B) Positioning on operative side puts pressure on the suture lines and on the shunt valve. Elevation of head in immediate postoperative period may cause rapid reduction of cerebrospinal fluid. (C) Placement on operative side puts pressure on the suture lines and shunt valve. (D) Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.



A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:

  1. Impaired communication
  2. Sensory-perceptual alterations
  3. Altered thought processes
  4. Impaired social interaction

Answer(s): B

Explanation:

(A) Impaired communication refers to decreased ability or inability to use or understand language in an interaction. (B) In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). (C) An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). (D) In impaired social interaction, the individual participates too little or too much in social interactions.



Painless vaginal bleeding in the last trimester may be caused by:

  1. Menstruation
  2. Abruptio placentae
  3. Placenta previa
  4. Polyhydramnios

Answer(s): C

Explanation:

(A) Menstruation should not occur during pregnancy. (B) Abruptio placentae is marked by painful vaginal bleeding following a premature placental detachment after 20th week of gestation. (C) A low-lying placenta separates from the uterine wall as the uterus contracts and cervix dilates. This separation causes painless bleeding in the 7th-8th month. (D) Polyhydramnios is excessive amniotic fluid.



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