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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 30 )

Updated On: 12-Jan-2026
Page 30 of 345
PDF with 862 Questions

When teaching a class of nursing students, the nurse asks why the embryonic period (weeks 4­8) of pregnancy is so critical.

  1. Duplication of genetic information takes place.
  2. Organogenesis occurs.
  3. Subcutaneous fat builds up steadily.
  4. Kidneys begin to secrete urine.

Answer(s): B

Explanation:

(A) Duplication of genetic material occurs during the preembryonic period (weeks 1­3) following conception. The exact duplication of genetic material is essential for cell differentiation, growth, and biological maintenance of the organism. (B) Weeks 4­8, known as the embryonic period, are the time organogenesis occurs and pose the greatest potential for major congenital malformations. All major internal and external organs and systems are formed. (C) Subcutaneous fat does not develop until the latter weeks of gestation. (D) Kidneys begin to secrete urine during the 13th­16th week.



As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he appears depressed and talks about suicide and feelings of worthlessness. This is an important factor to consider in planning for his care because:

  1. It may be a bid for attention and an indication that more diversionary activity should be planned for him
  2. No threat of suicide should be ignored or challenged in any way
  3. He needs to be observed carefully for signs that his depression has been relieved
  4. He needs to be confronted with his feelings and forced to work through them

Answer(s): B

Explanation:

(A) Threats of suicide should always be taken seriously. (B) This client has a life-threatening chronic illness. He may be concerned about dying or he may actually be contemplating suicide. (C) Sometimes clients who have made the decision to commit suicide appear to be less depressed. (D) Forcing him to look at his feelings may cause him to build a defense against the depression with behavioral or psychosomatic disturbances.



Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to improving withdrawn behavior is:

  1. Assigning her to occupational therapy
  2. Having her sit with the nurses while they chart
  3. Helping her to make friends
  4. Facilitating communication

Answer(s): D

Explanation:

(A) The nurse does not make this assignment. (B) One-to-one observation is not appropriate. It does not focus on the client or encourage communication. (C) The client is too suspicious to accomplish this goal. (D) The withdrawn individual must learn to communicate on a one-to-one level before moving on to more threatening situations.



A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?

  1. Hold the child's discharge for 1 hour.
  2. Notify the physician immediately.
  3. Discharge the child as the physician ordered.
  4. Administer an antiemetic as necessary.

Answer(s): B

Explanation:

(A) Holding the child's discharge alone does not address the client's problem. (B) Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should benotified immediately so that a serum theophylline level can be ordered. Theophylline dose should be withheld until the physician is notified. (C) The child must be evaluated for theophylline toxicity before any discharge. (D) Cause of the nausea should be investigated before the administration of an antiemetic.



A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:

  1. A blood pressure reading of 130/70 with a 5-lb weight loss
  2. No side effects from antihypertensive medication and an accurate pill count
  3. No evidence of increased left ventricular hypertrophy on chest x-ray
  4. Serum blood levels of the antihypertensive medication within therapeutic range

Answer(s): A

Explanation:

(A) A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. (B) Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. (C) Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. (D) Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.



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