NCLEX REVIEW GERIATRICS

1. A client has died, and the nurse asks a family member about the funeral
arrangements. The family member refuses to discuss the issue. Which is the
appropriate nursing action?
-Remain with the family member without discussing funeral arrangements.
2. The nursing instructor asks a nursing student to describe the procedure for
relieving an airway obstruction on an unconscious pregnant woman at 8 months'
gestation. How should the student describe the procedure correctly?
-Place a rolled blanket under the right abdominal flank and hip area.
3. The nurse on the day shift walks into a client's room and finds the client
unresponsive. The client is not breathing and does not have a pulse, and the
nurse immediately calls out for help. The next nursing action is which?
-Start chest compressions.
4. The nurse witnesses a neighbor's husband sustain a fall from the roof of his
house. The nurse rushes to the victim and determines the need to open the
airway. The nurse opens the airway in this victim with the use of which method?

-Jaw thrust maneuver

5. The nurse understands that which is a correct guideline for adult

cardiopulmonary resuscitation (CPR) for a health care provider?
-Each rescue breath should be given over 1 second and should produce a visible
chest rise.
6. The nurse attempts to relieve an airway obstruction on a 6-year-old conscious
child. Which location is the correct placement of the hands to perform this
maneuver?

-Between the umbilicus and the xiphoid process

7. The nurse is performing cardiopulmonary resuscitation (CPR) on an adult. The

nurse should deliver how many breaths per minute to the client?

-10

8. The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When

performing chest compressions, which is the compression rate for an infant?

-100 times per minute

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9. Which is the most appropriate location for assessing the pulse of an infant who is
less than 1 year old?

-Brachial

10. The nurse educator is teaching principles of cardiopulmonary resuscitation to a

group of nursing students. The nurse asks a student to describe the reason why
blind finger sweeps are avoided in infants. The nurse determines that the student
understands the reason if the student makes which statement?

-"The object may be forced back further into the throat."

11. The nurse is performing cardiopulmonary resuscitation (CPR) on an adult client.

How far should the sternum be depressed in an adult client for effective chest
compressions?

-2 inches

12. The nurse is caring for an older client who is reminiscing about past life
experiences in a positive manner. The nurse plans care with the understanding
that this behavior indicates which?

-A normal psychosocial response

13. The nurse is preparing to care for a dying client, and several family members are
at the client's bedside. Which therapeutic techniques should the nurse use when
communicating with the family? Select all that apply.

-Encourage expression of feelings, concerns, and fears.

-Touch and hold the client's or family member's hand if appropriate.
-Be honest and let the client and family know that they will not be abandoned by
the nurse.

14. Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that
the anterior fontanel has not closed and is soft and flat. Which action should the
nurse take?
-Document the findings.
15. An older client has been prescribed digoxin (Lanoxin). The nurse understands
that which age-related change would place the client at risk for digoxin toxicity?

-Decreased lean body mass and glomerular filtration rate

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16. The nurse should plan which to encourage rebreak in the client who is a resident
in a long-term care facility?

-Choosing his social activities

17. When the nurse is collecting data from the older adult, which findings should be
considered normal physiological changes? Select all that apply.

-Decline in visual acuity

-Increased susceptibility to urinary tract infections
-Increased incidence of awakening after sleep onset

18. The nurse is providing an education class to healthy older adults. Which exercise
will best promote health maintenance?

-Walking three to five times a week for 30 minutes

19. The nurse should implement which activity to promote reminiscence among older
clients?

-Having storytelling hours

20. The clinic nurse is assisting to perform a focused data collection process on a
client who is complaining of symptoms of a cold, a cough, and lung congestion.
Which should the nurse include for this type of data collection? Select all that
apply.

-Auscultating lung sounds

-Obtaining the client's temperature
-Obtaining information about the client's respirations

21. A client with a diagnosis of asthma is admitted to the hospital with respiratory
distress. Which type of adventitious lung sounds should the nurse expect to note
documented in the health record when collecting data related to the respiratory
system for this client?

-Wheezes

22. The nurse is reviewing the client's health record and notes that the client elicited
a positive Romberg sign. The nurse understands that this indicates which
finding?
-A significant sway when the client stands erect with feet together, arms at the
side, and the eyes closed
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23. The nurse notes documentation that a client is exhibiting Cheyne-Stokes

respirations. On data collection of the client, the nurse expects to note which
finding?

-Rhythmic respirations with periods of apnea

24. The nurse notes documentation that a client has conductive hearing loss. The
nurse understands that which is a cause of this type of hearing loss?

-A physical obstruction to the transmission of sound waves

25. While collecting data related to the cardiac system on a client diagnosed with an
incompetent heart valve, the nurse auscultates a murmur. Which best describes
the sound of a heart murmur?

-Gentle, blowing or swooshing noise

26. The nurse is preparing to assist the health care provider to test the extraocular
movements in a client for muscle weakness in the eyes. The nurse anticipates
that which physical assessment technique will be done to assess for muscle
weakness in the eye?

-Testing the six cardinal positions of gaze

27. The nurse is reinforcing instructions for a client in how to perform a testicular self-
examination (TSE). The nurse explains that which is the best time to perform this
exam?

-After a shower or bath

28. The nurse notes that the physical assessment findings for a client with meningeal
irritation indicate a positive Brudzinski sign. The nurse understands that which
observation was made?

-The client passively flexes the hip and knee in response to neck flexion and
reports pain in the vertebral column.

29. The nurse in the newborn nursery receives a telephone call to prepare for the
admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4.
When planning for the admission of this infant which is the nurse's highest
priority?

-Connecting the resuscitation bag to the oxygen outlet

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30. The nurse is preparing to perform an abdominal examination. The initial step
should be which?

-Inspection

31. The nurse is caring for a client on a cardiac monitor who is alone in a room at the
end of the hall. The client has a short burst of ventricular tachycardia (VT),
followed by ventricular fibrillation (VF). The client suddenly loses consciousness.
Which intervention should the nurse do first?

-Call for help and initiate cardiopulmonary resuscitation (CPR).

32. To use an external cardiac defibrillator on a client, which action should be

performed to check the cardiac rhythm?

-Applying the adhesive patch electrodes to the skin and moving away from the
client

33. The nurse is preparing to care for a dying client, and several family members are
at the client's bedside. Which therapeutic techniques should the nurse use when
communicating with the family? Select all that apply.

-Encourage expression of feelings, concerns, and fears.

-Extend, touch, and hold the client's or family member's hand if appropriate.
-Be honest and truthful, and let the client and family know that you will not
abandon them.

34. Which data would indicate a potential complication associated with age-related
changes in the musculoskeletal system?

-Overall sclerotic lesions

35. The nurse is caring for an older client who is terminally ill. Which signs indicate to
the nurse that death may be imminent?
-Irregular, noisy breathing and cold, clammy skin
36. The nursing student is asked to describe the correct steps for performing adult
cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the
order of priority.
-Determine unconsciousness by shaking the client and asking, "Are you OK?"
-Perform chest compressions.
-Open the client’s airway
-Initiate breathing
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37. The nurse is preparing to auscultate a client's abdomen for bowel sounds. The
nurse listens for bowel sounds in which abdominal quadrant first? Refer to figure.

#3

38. The nurse is checking a dark-skinned client for the presence of petechiae. Which
body area is best for the nurse to check in this client?

-Oral mucosa

39. The nurse is reinforcing instructions regarding cardiopulmonary resuscitation

(CPR) to a group of nursing students. The nurse tells the group that when
performing chest compressions on adults, the sternum should be depressed to
least which depth?

-2 inches

40. An older client confides to the visiting nurse the fear of falling while going to the
bathroom at night. Which statement indicates an understanding of the visual
changes affecting the older client?

-"Keep a red light on in the bathroom at night."

41. The nurse is providing information to unlicensed assistive personnel (UAP)

regarding caring for the older adult. The nurse tells the UAPs that which situation
portrays ageism?

-Advising older adults to forgo aggressive treatment

42. The nurse assigned to care for an older adult client places an extra blanket in the
client's room. The nurse understands that the older adult is less able to regulate
hot and cold body changes because of alterations in the activity of which gland?
-Sweat glands
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43. The nurse is collecting data from an older adult client. Which indicates a potential
complication associated with the skin of this client?

-Crusting

44. The nurse is collecting medication information from a client, and the client states
that she is taking garlic as an herbal supplement. The nurse understands that the
client is most likely treating which condition?

-Hyperlipidemia

45. The nurse is asked to test the visual acuity of a client using a Snellen chart. The
nurse prepares to perform the test, knowing that which identifies the accurate
procedure for this visual acuity test?

-The right eye is tested, followed by the left eye, and then both eyes are tested.

46. A client's vision is tested with a Snellen chart. The results of the test are
documented as 20/60. How should the nurse interpret this result?

-The client can read at a distance of 20 feet what a client with normal vision can
read at 60 feet.

47. The nurse is preparing the client for eye testing, and the examiner is planning to
test the eyes using the confrontational method. What should the nurse tell the
client about the purpose of the test?

-Examines visual fields or peripheral vision

48. An older client is at risk for falls. When developing an individualized plan of care
for this client, the nurse recalls that which concept is least relevant to
maintenance of balance for the older client?

-Older clients cannot think quickly enough to respond to emergencies.

49. In planning care for older clients in a long-term care facility, the nurse recalls that
which is accurate regarding sexuality and the older client?

-Although responses may be slower, sexual ability is present in later years of life.
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50. The nurse is working with an older client and family about discharge following
hospitalization. When initiating discussions with the group, the nurse understands
that older persons usually prefer which?

-To live independently, but close to their children

51. An older client is taking multiple medications for a variety of health problems. The
nurse should monitor the results of which most important laboratory test(s) when
evaluating adverse effects of medication therapy in the older adult?

-Creatinine

52. The nurse working in a long-term care facility is approached by the son of a
resident, who wants his 78-year-old father to have a heating pad because "his
feet are always cold at night." The nurse should incorporate which concept when
formulating a response to the family member?

-Older adults often have slower neurological response times and are therefore
more at risk for burns.

53. The nurse has gathered data regarding an older client. The nurse understands
that which indicator of fluid imbalance is not reliable for a client in this age group?

-Thirst

54. The nurse is told by an older woman that she has begun to be incontinent of
urine at night and now drinks no fluids after 6:00 pm. The nurse's response
should be guided by which knowledge?
-Incontinence at any age deserves urological attention.
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55. The nurse is preparing to perform an abdominal assessment on a client. The

nurse places the client in which best position to perform the assessment?

#2
56. A client who has been seen in the clinic has been diagnosed with endometriosis
and asks the nurse to describe this condition. The nurse bases the response on
what information?

-Endometriosis is the presence of tissue outside the uterus that resembles the
endometrium.

57. A nursing instructor asks a nursing student about the reason for the reduction of
anesthetic medication dosage in the older person. Which statement is an
appropriate response?

-"The increase of fatty tissue allows anesthetic agents, which have an affinity for
fatty tissue, to concentrate in body fat."

58. The nurse recognizes that which intervention is unlikely to facilitate effective
communication between a dying client and the family?
-The nurse makes decisions for the client and family in order to relieve them of
unnecessary demands
59. A 39-year-old man learned today that his 36-year-old wife has an incurable
cancer and is expected to live not more than a few weeks. The nurse identifies
which response by the husband as indicative of effective individual coping?

-He expresses his anger at God and the health care providers for allowing this to
happen.

60. The nurse determines that a student in a basic cardiac life support (BCLS)
course correctly performs cardiopulmonary resuscitation (CPR) on an infant
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when the nurse observes which rate of chest compressions delivered to the
infant mannequin?

-100 times per minute

61. A client and her husband are being discharged from the hospital after delivering a
stillborn infant. They ask about the possibility of attending a bereavement support
group in the community. Which response should this request indicate to the
nurse?

-Normal grieving

62. Which observation indicates that the nurse is performing a whispered voice
hearing assessment test procedure correctly?
-Asks the client to block one ear at a time
63. The nurse is preparing to collect client data by examining the abdomen. The
nurse should begin the assessment by performing which action first?

-Inspecting the abdomen

64. The nurse is caring for a client with terminal cancer who is close to death. In
reviewing the plan of care, the nurse determines that which action is a priority?

-Maintain the client's dignity and self-esteem, and make the client as comfortable
as possible.

65. The nurse provides information to a client regarding breast self-examination

(BSE). Which client statement indicates a need for further teaching regarding
BSE?

-"I don't need to do that; I'm too old for that."

66. A nursing student enrolled in a physical assessment course is asked to describe

the probable signs of pregnancy. Which are probable signs indicating possible
pregnancy? Select all that apply.

-Hegar's, Chadwick's, McDonald’s

67. A client who was struck by a car while jogging is brought to the emergency
department by the ambulance team. The client is unconscious, and a ruptured
spleen is suspected. Emergency measures are instituted but are unsuccessful.
The client's fiancée is with the client and tells the nurse that the client is an organ
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donor. In anticipation that the client's eyes will be donated, which should the
nurse implement?

-Close the deceased client's eyes and place a small ice pack on the eyes.

68. The nurse is checking the apical heart rate of a client with a complaint of angina.
The nurse places the stethoscope in which anatomical area? Refer to figure.

#4
69. When collecting physical assessment data, the nurse understands that the
spleen is located in which abdominal quadrant? Refer to figure.

#2
70. When performing cardiopulmonary resuscitation (CPR), the nurse should deliver
how many breaths per minute to an adult client?

-10

71. The nurse is providing cardiopulmonary resuscitation (CPR) to an adult cardiac

arrest victim. Which is the proper compression-to-ventilation ratio for one-person
CPR?

-30:2
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72. The nurse caring for the older adult client understands that dosages of many
medications are reduced in this population because of which fact?

-Serum albumin levels are decreased.

73. The nurse prepares to discharge a client who is experiencing family-related

stress. Which goal does the nurse include to help the client achieve the primary
developmental task?

-Help the client resume her familial role.

74. A client has a terminal illness, and her spouse is distraught about the unrelenting
pain she experiences. Which should the nurse implement as the most effective
measure to alleviate the spouse's distress?

-Engage the spouse in providing comfort.

75. A client's spouse becomes distraught when thinking about his wife's grave
prognosis. Which action should the nurse implement to promote hope for the
spouse?

-Encourage formation of achievable goals.

76. To assess for the presence of the posterior tibialis pulse, the nurse should
palpate which areas?

-In the groove behind the medial malleolus and the Achilles tendon

77. A licensed practical nurse (LPN) is providing instructions to an unlicensed

assistive personnel (UAP) who is preparing to care for a deceased client whose
eyes will be donated. The nurse intervenes if the UAP performs which action?

-Places a dry sterile dressing over the open eyes

78. A licensed practical nurse (LPN) is a certified basic life support (BLS) instructor.
The LPN is conducting a BLS recertification class and is discussing automated
external defibrillation. A member of the class asks the LPN to identify the correct
location for the placement of conductive gel pads to treat ventricular fibrillation.
The LPN tells the class that the conductive gel pads are placed in which location
on the client's chest?

-Under the right clavicle and to the left of the precordium

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79. The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse
should place the hands in which position to begin chest compressions?

-On the lower half of the sternum

80. The nurse should use which best method to open the victim's airway if the victim
sustained a neck injury?

-Jaw thrust maneuver

81. The nurse notes that an 8-year-old child is choking but is awake and alert at this
time. As the nurse rushes to aid the child, the nurse plans to place the hands
between which landmarks to remove the foreign body?

-The umbilicus and xiphoid process

82. The nurse employed in the pediatric unit working on the 11:00 ᴘᴍ to 7:00 ᴀᴍ shift
finds an infant unresponsive and without respiration or a pulse. The nurse plans
to deliver chest compressions at a rate of at least which?

-100 times per minute

83. The nurse arrives at the scene of a code and begins to assist in performing
cardiopulmonary resuscitation (CPR) on an adult client. After determining proper
hand placement, the nurse begins delivering compressions by pushing down on
the chest at which depth?

-2 inches

84. An automatic external defibrillator (AED) is available to treat a client who goes
into cardiac arrest. The nurse uses this equipment to determine cardiac rhythm
by doing which?

-Applying the adhesive patch electrodes to the skin and moving away from the
client

85. An automatic external defibrillator (AED) interprets that the rhythm of a pulseless
client is ventricular fibrillation. The nurse takes which action next?

-Orders personnel away from the client, charges the machine, and depresses the
discharge buttons
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86. The nurse witnesses a person starting to choke in the hospital cafeteria. Before
performing abdominal thrusts, which action should the nurse perform?

-Ask the client, "Are you choking?"

87. The nurse is conducting a teaching session on basic life support (BLS) for
nursing students. Which statement made by a nursing student indicates a need
for further teaching?

-"I will remember the algorithm airway, breathing, and compressions to guide my
actions when providing BLS."

88. The nurse-midwife is conducting a session on the process of fertilization with a

group of nursing students. The nurse-midwife asks a nursing student to identify
the structure in which fertilization of an ovum takes place. The student answers
correctly by identifying which location?
-Fallopian tube
89. The nurse is collecting data from a client who is suspected of having
mittelschmerz. Which finding should the nurse expect to note on data collection
of the client?

-Sharp pain located on the right side of the pelvis

90. The nurse employed in the emergency department is collecting data on a 7-year-
old child with a fractured arm. The child is hesitant to answer questions that the
nurse is asking and consistently looks at the parents in a fearful manner. The
nurse suspects physical abuse and continues with the data collection
procedures. Which finding would most likely assist in verifying the suspicion?

-Bald spots on the scalp

91. The nurse is auscultating bowel sounds. Which are appropriate data collection
methods? Select all that apply.

-Divide the abdomen into four quadrants at the umbilicus.

-Do not feed the client if no sounds are audible in 5 minutes.
-Listen in each quadrant for gurgling sounds indicating movement.

92. The nurse is caring for an 8-year-old child in the late stage of a terminal illness.
The child is semiconscious. The nurse notices that the child has a dry mouth and
the family believes the child is thirsty. The family is attempting to give the child a
large glass of apple juice. Which actions should the nurse take? Select all that
apply.
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-Perform frequent oral care with mouth swabs.

-Encourage the family to participate in oral care as much as desired.
-Give the child small sips of water or ice chips if alert and requested by the child.

93. The nurse is caring for a client at the end of life. Which late cardiovascular and
respiratory findings should the nurse expect to note while collecting data? Select
all that apply.

-Irregular heart rate

-Decreased pulse rate
-Decreased blood pressure
-Irregular breathing patterns

94. The nurse is creating a care plan for a client with a terminal illness. Which
nursing actions should be included? Select all that apply.
-Respond to requests from the client and family promptly.
-Support the client's decision-making in order to promote client control.
-Provide information about what to expect during the dying process to the client
and family.

95. The nurse is caring for a client at the end of life. Which gastrointestinal findings
indicate that death is approaching? Select all that apply.

-Nausea
-Incontinence
-Accumulation of gas
-Abdominal distention

96. The nurse is caring for a client at the end of life. Which skin changes would the
nurse expect to note? Select all that apply.

-Waxlike texture
-Mottling of arms, legs, hands, and feet
-Cyanosis of the nose, nail beds, and knees

97. The nurse is caring for a client at the end-of-life. The client is withdrawn and
agitated and is experiencing visual hallucinations. Which actions should the
nurse take to provide end-of-life psychological care? Select all that apply.
-Provide privacy to the client and family.
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-Encourage the family to talk with and reassure the client.

-Encourage visits by appropriate spiritual services as desired.

98. The nurse is caring for a client who has just died. Which end-of-life information
needs to be documented in the client's medical record? Select all that apply.

-Time and date of death

-Time of body transfer and destination
-Name of health care provider certifying death
-Medical tubes, devices, or lines left in the body