Cisco
CompTIA
ISC
EC-Council
EXIN
Fortinet
ITIL
Juniper
Microsoft
VMware
Avaya
SAP
Google
NVIDIA
Salesforce
Amazon
Palo Alto Networks
ISC2
Splunk
ServiceNow
All Vendors
  2. Home
  3. Exams
  4. NCLEX
  5. NCLEX-RN

NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 50 )

Updated On: 12-Jan-2026
Page 50 of 345
PDF with 862 Questions

Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities

  1. 7
  2. 10
  3. 8
  4. 9

Answer(s): A

Explanation:

(A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. (C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. (D) For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point.



The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:

  1. Discontinue the IV
  2. Stop the medication, and begin a normal saline infusion
  3. Take all vital signs, and report to the physician
  4. Assess urinary output, and if it is 30 mL an hour, maintain current treatment

Answer(s): B

Explanation:

(A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.



A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:

  1. Overeating and subsequent obesity
  2. Obesity prior to conception
  3. Hypertension due to kidney lesions
  4. Fluid retention

Answer(s): D

Explanation:

(A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.



A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?

  1. "If he develops diarrhea lasting for more than 2­3 days, I will contact the doctor or nurse."
  2. "I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings."
  3. "It is important to keep the head of his bed elevated or sit him in the chair during feedings."
  4. "I should use prepared or open formula within 24 hours and store unused portions in the refrigerator."

Answer(s): B

Explanation:

(A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (12 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the client's head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.



A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:

  1. Explain that he will be kept NPO for 24 hours before the exam
  2. Practice with him so he will be able to hold his breath for 1 minute
  3. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
  4. Explain that his vital signs will be checked frequently after the test

Answer(s): D

Explanation:

(A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5­10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock.



Viewing page 50 of 345
Viewing questions 246 - 250 out of 862 questions



Post your Comments and Discuss NCLEX NCLEX-RN exam prep with other Community members:

Join the NCLEX-RN Discussion