Free NCLEX Test with Answer 2020/ 2021 130th Edition

Free NCLEX Test with Answer 2020/ 2021 130th Edition

1. A nurse is monitoring the fluid balance of a client with human immunodeficiency virus (HIV). Since loss of subcutaneous adipose tissue and muscle atrophy occurs in clients with HIV, the nurse understands that which of the following will provide the most reliable indicator of fluid balance in this client?

A. Presence of vomiting and/or diarrhea
B. Decreased urine output and hypotension
C. Moistness of the skin
D. Skin turgor with tenting

Answer: B. Decreased urine output and hypotension

Rationale: With the loss of muscle mass and adipose tissue, the overlying skin loses its support. The usual elasticity of skin becomes a less reliable indicator of body fluid status. Vomiting and diarrhea may cause weight loss and electrolyte imbalances, but the amount that is vomited does not precisely correlate with the amount of fluid remaining in the body since there are systems, such as the kidney, that can help to reestablish equilibrium. Decreased urine output and hypotension more accurately correlate with loss of fluid in this client population.

Test-Taking Strategy: Use the process of elimination and note the key words most reliable indicator. Eliminate options 3 and 4 first because they are similar. From the remaining options, focus on the key words to direct you to option B. Review the pathophysiology of HIV and the indicators of fluid balance if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Fundamental Skills
References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders,
pp. 231-234, 2378-2380.
Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 216.

2. A nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understood the instructions if she states that:

A. She should alternately contract and relax the muscles of the perineal area
B. The use of postpartum exercises can result in stress urinary incontinence
C. Exercise should be delayed for 4 weeks to allow healing time
D. Strenuous exercises should be started while in the hospital

Answer: A. She should alternately contract and relax the muscles of the perineal area

Rationale: Kegel exercises are extremely important to strengthen the muscle tone of the perineal area. Postpartum exercises can begin soon after birth. The initial exercises should be simple with progression to increasingly strenuous exercises. Women who maintain the perineal muscle tone may benefit in later life by the development of less stress urinary incontinence.

Test-Taking Strategy: Use the process of elimination and note the key words understood the instructions. Focusing on the issue, proper knowledge of the procedure and importance of postpartum exercises, will direct you to option A. Review postpartum instructions related to exercise if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 210-21A.

3. A newborn infant has coarctation of the aorta (COA). The nurse would expect to note which of the following findings in the infant?

A. Cool upper extremities
B. Hepatomegaly
C. Blood pressure low in the upper extremities and high in the lower extremities
D. Bounding radial pulses, absent or weak femoral and pedal pulses

Answer: D. Bounding radial pulses, absent or weak femoral and pedal pulses

Rationale: When there is narrowing within the aorta, there is increased pressure proximal to the defect and decreased pressure distal to it. Therefore one would expect bounding pulses in the arms and weak or absent pulses in the femoral and/or pedal areas. With decreased blood supply to the lower extremities, those areas would be cool to touch. The upper extremities would be warm. The other options are incorrect.

Test-Taking Strategy: Review each of the options listed, anticipating the effects of coarctation on the circulatory dynamics of the infant. Eliminate options 1 and 3 first, which are the opposite of the expected findings. Hepatomegaly is an associated finding if the infant goes into heart failure as a complication of COA. With this in mind, eliminate option B. Review the manifestations associated with COA 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/Postpartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 619-620.

4. A 1-year-old child has an order for Lanoxin (digoxin) to treat congestive heart failure (CHF). The nurse would plan on withholding the ordered dose of the medication if:

A. A dose is missed, and 1 hour has elapsed
B. The child has a fever
C. The child’s pulse is less than 80 beats/min
D. The child’s pulse is more than 100 beats/min

Answer: C. The child’s pulse is less than 80 beats/min

Rationale: The normal pulse rate for a 1-year-old child is about 100 beats/min. A dose missed is withheld if 4 hours have elapsed. Fever is not a contraindication to giving the medication. Knowing that a sign of digoxin toxicity is a decreased heart rate, the most likely choice is option 3, which indicates a relative bradycardia.

Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating option A. A dose missed is withheld if 4 hours have elapsed. Recalling that a fever is not a contraindication to giving the medication, eliminate option 2 next. Choose correctly between the remaining options by recalling the direction of change in the pulse rate that would occur with digoxin toxicity. Knowing that a sign of digoxin toxicity is a decreased heart rate will direct you to option C. Review the guidelines related to administering digoxin if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Child Health
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 62D.

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