NCLEX Based MCQs #2
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Q.1 The nurse calculates the 1-minute Apgar score for a neonate with the following:
1. Respiratory effort: slow;
2. heart rate: 120 bpm;
3. muscle tone: some flexion of extremities;
4. reflex irritability: vigorous ( उर्जायक्
ु त );
5. skin color: body pink, blue extremities.
What score does the nurse assign?
a.7
b.10
c.9
d.8
Correct Answer :-
1
Apgar is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score
determines how well the baby tolerated the birthing process. The 5-minute score tells the health
care provider how well the baby is doing outside the mother's womb. Scoring is 0, 1, or 2 for
, each category. A perfect Apgar score is 10. Scoring categories are as follows: 1. Respiratory
effort: 0 = not breathing, 1 = slow or irregular, 2 = strong cry. 2. Heart rate by stethoscope; 0 =
no HR, 1 = < 100 bpm, 2 = > 100 bpm. 3. Muscle tone: 0 = loose/floppy, 1 = some tone, 2 =
active motion. 4. Reflex irritability or grimace response: 0 = no reaction, 1 = grimacing, 2 =
cough, sneeze, or cry. 5. Skin color: 0 = pale blue, 1 = body pink, extremities blue, 2 = entire
body pink. Hence, the nurse assigns a 1-minute Apgar score of 7 to this infant.
Q.2 When the nurse enters a patient's room to administer insulin, the patient is in an awkward (
असवि
ु धाजनक ) position in her bed. What should the nurse do FIRST?
1.Verify the patient's name.
2.Administer the insulin.
3.Reposition the patient.
4.Check the patient's ID band.
Correct Answer :- 3
The nurse's first task is to make the patient comfortable. Once the patient is repositioned, the
nurse can proceed to check the patient's ID band and ask the patient to state her name. The
nurse may then administer the insulin.
Q. 3 The nurse is providing wound care for a client with a Stage III pressure ulcer. Which of the
following signs indicates that the wound is healing?
1.The wound bed is getting smaller.
2.Appearance of a serum-filled blister.
3.Skin is red and does not blanch when pressed.
4.Eschar covers the wound area.
Correct Answer 1
According to the National Pressure Ulcer Staging System, Stage III. Full thickness skin loss
involving damage or necrosis of subcutaneous tissue that may extend down to, but not through,
underlying fascia. Signs of healing include: the sore gets smaller; pinkish tissue starts forming
along the edges, moving to the center; some bleeding may be present, indicating good
circulation to the area. Eschar is dead tissue; when it covers a pressure ulcer, the wound can't
be staged. Skin that is red and doesn't blanch when pressed indicates a Stage I ulcer.
Appearance of a serum-filled blister occurs in Stage II.
Q.4 A client has a nephrostomy tube. When the nurse assists the client to ambulate, which is
the best way to keep the tube safe?
1.Attach the tube to a leg collection bag.
2.Ask the client to hold the drainage bag.
3.Use a walker and tie the drainage bag.
4.Clamp the tube during ambulation.
Correct Answer :- 1
The nurse should attach the nephrostomy tube to a leg collection bag during ambulation ( Ability
to walk ). This allows easier movement and maintains the collection bag below waist level. The
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Q.1 The nurse calculates the 1-minute Apgar score for a neonate with the following:
1. Respiratory effort: slow;
2. heart rate: 120 bpm;
3. muscle tone: some flexion of extremities;
4. reflex irritability: vigorous ( उर्जायक्
ु त );
5. skin color: body pink, blue extremities.
What score does the nurse assign?
a.7
b.10
c.9
d.8
Correct Answer :-
1
Apgar is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score
determines how well the baby tolerated the birthing process. The 5-minute score tells the health
care provider how well the baby is doing outside the mother's womb. Scoring is 0, 1, or 2 for
, each category. A perfect Apgar score is 10. Scoring categories are as follows: 1. Respiratory
effort: 0 = not breathing, 1 = slow or irregular, 2 = strong cry. 2. Heart rate by stethoscope; 0 =
no HR, 1 = < 100 bpm, 2 = > 100 bpm. 3. Muscle tone: 0 = loose/floppy, 1 = some tone, 2 =
active motion. 4. Reflex irritability or grimace response: 0 = no reaction, 1 = grimacing, 2 =
cough, sneeze, or cry. 5. Skin color: 0 = pale blue, 1 = body pink, extremities blue, 2 = entire
body pink. Hence, the nurse assigns a 1-minute Apgar score of 7 to this infant.
Q.2 When the nurse enters a patient's room to administer insulin, the patient is in an awkward (
असवि
ु धाजनक ) position in her bed. What should the nurse do FIRST?
1.Verify the patient's name.
2.Administer the insulin.
3.Reposition the patient.
4.Check the patient's ID band.
Correct Answer :- 3
The nurse's first task is to make the patient comfortable. Once the patient is repositioned, the
nurse can proceed to check the patient's ID band and ask the patient to state her name. The
nurse may then administer the insulin.
Q. 3 The nurse is providing wound care for a client with a Stage III pressure ulcer. Which of the
following signs indicates that the wound is healing?
1.The wound bed is getting smaller.
2.Appearance of a serum-filled blister.
3.Skin is red and does not blanch when pressed.
4.Eschar covers the wound area.
Correct Answer 1
According to the National Pressure Ulcer Staging System, Stage III. Full thickness skin loss
involving damage or necrosis of subcutaneous tissue that may extend down to, but not through,
underlying fascia. Signs of healing include: the sore gets smaller; pinkish tissue starts forming
along the edges, moving to the center; some bleeding may be present, indicating good
circulation to the area. Eschar is dead tissue; when it covers a pressure ulcer, the wound can't
be staged. Skin that is red and doesn't blanch when pressed indicates a Stage I ulcer.
Appearance of a serum-filled blister occurs in Stage II.
Q.4 A client has a nephrostomy tube. When the nurse assists the client to ambulate, which is
the best way to keep the tube safe?
1.Attach the tube to a leg collection bag.
2.Ask the client to hold the drainage bag.
3.Use a walker and tie the drainage bag.
4.Clamp the tube during ambulation.
Correct Answer :- 1
The nurse should attach the nephrostomy tube to a leg collection bag during ambulation ( Ability
to walk ). This allows easier movement and maintains the collection bag below waist level. The
