Free NCLEX Questions Test Bank 2020 / 2021 115th Edition

Free NCLEX Questions Test Bank 2020 / 2021 115th Edition

1. A nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies knowing that which of the following is an unassociated finding with this diagnosis?

A. Elevated levels of human chorionic gonadotropin (HCG)
B. Vaginal bleeding
C. No fetal heart activity
D. Hypotension

Answer: D. Hypotension

Rationale: The most common signs and symptoms of gestational trophoblastic disease include elevated levels of HCG, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancy-induced hypertension. An elevated blood pressure would also be noted.

Test-Taking Strategy: Note the key word unassociated in the question. This word indicates a false response question and that you need to select the incorrect finding. Remember, hypertension would occur in this disorder. Review the clinical findings in gestational trophoblastic disease if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 215.

2. A nurse is providing instructions to a pregnant client regarding the need to consume folic acid in the diet. The nurse determines that the client understands the instructions when the client states that it is necessary to include which of the following food items in the diet?

A. Chicken
B. Rice
C. Cheese
D. Green, leafy vegetables

Answer: D. Green, leafy vegetables

Rationale: Sources of folic acid include green, leafy vegetables, whole grains, fruits, liver, dried peas, and beans. The foods listed in options 1, 2, and 3 are not sources of folic acid.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the food items that are high in folic acid to answer this question. Cheese is a dairy product and is high in calcium, and rice and chicken are good sources of iron. Green, leafy vegetables (option 4) are the foods high in folic acid. Review foods high in folic acid if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion/Maintenance
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 62.

3. A physician aspirates synovial fluid from the knee joint of a client with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and would expect the results to indicate which finding?

A. Cloudy synovial fluid
B. Presence of organisms
C. Bloody synovial fluid
D. Presence of urate crystals

Answer: A. Cloudy synovial fluid

Rationale: Cloudy synovial fluid is diagnostic of rheumatoid arthritis. Organisms present in the synovial fluid are characteristic of a septic joint condition. Bloody synovial fluid is seen with trauma. Urate crystals are found in gout.

Test-Taking Strategy: Use the process of elimination. Remember that organisms indicate infection, blood indicates trauma, and urate crystals indicate gout. Review the characteristics of rheumatoid arthritis if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Immune
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 112.

4. A nurse is collecting admission data on a client with Parkinson’s disease. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which of the following in the client’s record?

A. Positive Trousseau’s sign
B. Negative Trousseau’s sign
C. Negative Romberg’s test
D. Positive Romberg’s test

Answer: D. Positive Romberg’s test

Rationale: Romberg’s test checks for cerebellar functioning related to balance. The client stands with the feet together and the arms at the side and then closes the eyes. Slight swaying is normal, but loss of balance indicates a problem and a positive Romberg’s test. Trousseau’s sign indicates a calcium imbalance.

Test-Taking Strategy: A clue in the question is that the client has Parkinson’s disease because clients with this disorder often have interferences in balance. Remember, a positive Romberg’s test occurs when the client has a balance problem. Relate Romberg’s test to balance. Review these tests if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Neurological
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 585.

Read also:

• NCLEX Questions Test Bank 2020 / 2021 114th Edition
• NCLEX Questions Test Bank and Review 113th Edition
• NCLEX Questions Test Bank and Review 2019 / 2020 112th Edition

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