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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 47 )

Updated On: 12-Jan-2026
Page 47 of 345
PDF with 862 Questions

A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?

  1. She is compliant with her diet as previously taught.
  2. She needs further instruction and reinforcement.
  3. She needs to increase her caloric intake.
  4. She needs to be placed on a restrictive diet immediately.

Answer(s): B

Explanation:

(A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. (B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27­30 lb over the 9-month period. With rapid and excessive weightgain, PIH should also be suspected. (C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy.



A client with a C-3­4 fracture has just arrived in the emergency room. The primary nursing intervention is:

  1. Stabilization of the cervical spine
  2. Airway assessment and stabilization
  3. Confirmation of spinal cord injury
  4. Normalization of intravascular volume

Answer(s): B

Explanation:

(A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation.



A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks' gestation. The nurse should be alert to which condition related to her age?

  1. Iron-deficiency anemia
  2. Sexually transmitted disease (STD)
  3. Intrauterine growth retardation
  4. Pregnancy-induced hypertension (PIH)

Answer(s): D

Explanation:

(A) Iron-deficiency anemia can occur throughout pregnancy and is not age related. (B) STDs can occur prior to or during pregnancy and are not age related. (C) Intrauterine growth retardation is an abnormal process where fetal development and maturation are delayed. It is not age related. (D) Physical risks for the pregnant client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy.



An 8-year-old child comes to the physician's office complaining of swelling and pain in the knees. His mother says, "The swelling occurred for no reason, and it keeps getting worse." The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history?

  1. A decreased urinary output and flank pain
  2. A fever of over 103F occurring over the last 2­3 weeks
  3. Rashes covering the palms of the hands and the soles of the feet
  4. Headaches, malaise, or sore throat

Answer(s): D

Explanation:

(A) Urinary tract symptoms are not commonly associated with Lyme disease. (B) A fever of 103F is not characteristic of Lyme disease. (C) The rash that is associated with Lyme diseasedoes not appear on the palms of the hands and the soles of the feet. (D) Classic symptoms of Lyme disease include headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough.



Priapism may be a sign of:

  1. Altered neurological function
  2. Imminent death
  3. Urinary incontinence
  4. Reproductive dysfunction

Answer(s): A

Explanation:

(A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem.



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