Published - Fri, 03 Mar 2023

NCLEX-RN Exam Questions - Part 3

1. 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

A) 7
B) 10
C) 8
D) 9

2. A pregnant woman at 36 weeks gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk?

A) Fifty milliliters light cream and 2 tbsp corn syrup
B) Thirty grams powdered skim milk and 1 egg
C) One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrup
D) One package vitamin-fortified gelatin drink

3. The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, 'It - s not so easy for me to just go right to the hospital like that.' After acknowledging her feelings, which of these approaches by the nurse would probably be best?

A) Stress to the client that her husband would want her to do what is best for her health.
B) Explore with the client her perceptions of why she is unable to go to the hospital.
C) Repeat the physician - s reasons for advising immediate hospitalization.
D) Explain to the client that she is ultimately responsible for her own welfare and that of her baby.

4. Which of the following findings would be abnormal in a postpartal woman?

A) Chills shortly after delivery
B) Pulse rate of 60 bpm in morning on first postdelivery day
C) Urinary output of 3000 mL on the second day after delivery
D) An oral temperature of 101F (38.3C) on the third day after delivery

5. What is the most effective method to identify early breast cancer lumps?

A) Mammograms every 3 years
B) Yearly checkups performed by physician
C) Ultrasounds every 3 years
D) Monthly breast self-examination

1. Right Answer: 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.

2. Right Answer: B
Explanation: (A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein. Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption.

3. Right Answer: B
Explanation: (A) This answer does not hold the client accountable for her own health. (B) The nurse should explore potential reasons for the clients anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization. (C)Repeating the physicians reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. (D) The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the clients potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice?

4. Right Answer: D
Explanation: (A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (1224 hours) owing to diuresis. The kidneys must eliminate an estimated 20003000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than100.4F needs further investigation to identify any infectious process.

5. Right Answer: D
Explanation: (A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.

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