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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 64 )

Updated On: 25-Jan-2026
Page 64 of 345
PDF with 862 Questions

The predominant purpose of the first Apgar scoring of a newborn is to:

  1. Determine gross abnormal motor function
  2. Obtain a baseline for comparison with the infant's future adaptation to the environment
  3. Evaluate the infant's vital functions
  4. Determine the extent of congenital malformations

Answer(s): C

Explanation:

(A) Apgar scores are not related to the infant's care, but to the infant's physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores.



The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:

  1. Weigh once a week and report to the physician any weight gain of10 lb.
  2. Limit fluid intake to 500 mL/day.
  3. Store the medication in a refrigerator and allow to stand at room temperature for 30 minutes prior to administration.
  4. Hold the vial under warm water for 10­15 minutes and shake vigorously before drawing medication into the syringe.

Answer(s): D

Explanation:

(A) Weight should be obtained daily. (B) Fluid is not restricted but is given according to urine output. (C) The medication does not have to be stored in a refrigerator. (D) Holding the vial under warm water for 10­15 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.



To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?

  1. Stinging, burning when placed under the tongue
  2. Temporary blurring of vision
  3. Generalized urticaria with prolonged use
  4. Urinary frequency

Answer(s): A

Explanation:

(A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not even side effects.



The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, "My life is so bad no one can do anything to help me." The most helpful initial response by the nurse would be:

  1. "It concerns me that you feel so badly when you have so many positive things in your life."
  2. "It will take a few weeks for you to feel better, so you need to be patient."
  3. "You are telling me that you are feeling hopeless at this point?"
  4. "Let's play cards with some of the other clients to get your mind off your problems for now."

Answer(s): C

Explanation:

(A) This response does not acknowledge the client's feelings and may increase his feelings of guilt. (B) This response denotes false reassurance. (C) This response acknowledges the client's feelings and invites a response. (D) This response changes the subject and does not allow the client to talk about his feelings.



The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?

  1. Because fluoxetine is a tricyclic antidepressant, it may precipitate a hypertensive crisis.
  2. The therapeutic effect of the drug occurs 2­4 weeks after treatment is begun.
  3. Foods such as aged cheese, yogurt, soy sauce, and bananas should not be eaten with this drug.
  4. Fluoxetine may be administered safely in combination with monoamine oxidase (MAO) inhibitors.

Answer(s): B

Explanation:

(A) Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. (B) This statement is true. (C) These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors. Fluoxetine is not an MAO inhibitor. (D) Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors.



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