COMBO WITH OLDER ADULT NCLEX QUESTIONS
AND 1 OTHER
. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler
ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by:
1.Noting if the heart rate is greater than 140 BPM
2.Placing the diaphragm of the Doppler on the mother abdomen
3.Performing Leopold's maneuvers first to determine the location of the fetal heart
4.Palpating the maternal radial pulse while listening to the fetal heart rate - answer-4. The nurse
simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to
differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the
maternal heart rate for the fetal heart rate. Leopold's maneuvers may help the examiner locate the
position of the fetus but will not ensure a distinction between the two rates.
1.A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage
of labor when which of the following assessments is noted?
A.The client begins to expel clear vaginal fluid
B.The contractions are regular
C.The membranes have ruptured
D.The cervix is dilated completely - answer-1.4. The second stage of labor begins when the cervix is
dilated completely and ends with the birth of the neonate.
A 70-year-old client asks the nurse to explain to her about hypertension. An appropriate response by the
nurse as to why older clients often have hypertension is due to:
A. Myocardial muscle damage
B. Reduction in physical activity
C. Ingestion of foods high in sodium
D. Accumulation of plaque on arterial walls - answer-D. Accumulation of plaque on arterial walls
A 76-year-old adult female is brought to a neighborhood client after being found wandering around the
local park. The client appears disheveled and reports being hungry. Which of the following assessment
and interview findings would cause the nurse to suspect elder abuse? (Select all that apply.)
A. Falls asleep in the examination room
B. Repeatedly states, "Don't hurt me."
C. Chafing around wrists and ankles
D. Bruises in various stages of healing - answer-B. Repeatedly states, "Don't hurt me."
C. Chafing around wrists and ankles
D. Bruises in various stages of healing
A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife
prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client
that after this procedure, she will most likely have:
,1.Less pressure on her cervix
2.Increased efficiency of contractions
3.Decreased number of contractions
4.The need for increased maternal blood pressure monitoring - answer-2. Amniotomy can be used to
induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process
begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and
may increase the efficiency of contractions.
A client has been recently diagnosed with Alzheimer's disease. When teaching the family about the
prognosis, the nurse must explain that:
A. Diet and exercise can slow the process considerably
B. It usually progresses gradually with a deterioration of function
C. Many individuals can be cured if the diagnosis is made early
D. Few clients live more than 3 years after the diagnosis - answer-B. It usually progresses gradually with
a deterioration of function
A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is
transferred to the delivery room table, and the nurse places the client in the:
1.Trendelenburg's position with the legs in stirrups
2.Semi-Fowler position with a pillow under the knees
3.Prone position with the legs separated and elevated
4.Supine position with a wedge under the right hip - answer-4. Vena cava and descending aorta
compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This
leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. The best
position to prevent this would be side-lying with the uterus displaced off of abdominal vessels.
Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the
right hip provides displacement of the uterus.
A client is admitted to the birthing suite in early active labor. The priority nursing intervention on
admission of this client would be:
1.Auscultating the fetal heart
2.Taking an obstetric history
3.Asking the client when she last ate
4.Ascertaining whether the membranes were ruptured - answer-1. Determining the fetal well-being
supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention
is required.
A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3
cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is:
1.Not yet engaged
2.Entering the pelvic inlet
3.Below the ischial spines
, 4.Visible at the vaginal opening - answer-3. A station of +1 indicates that the fetal head is 1 cm below
the ischial spines.
A laboring client complains of low back pain. The nurse replies that this pain occurs most when the
position of the fetus is:
1.Breech
2.Transverse
3.Occiput anterior
4.Occiput posterior - answer-4. A persistent occiput-posterior position causes intense back pain because
of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does
not cause back pain.
A long-term care facility sponsors a discussion group on the administration of medications. The
participants have a number of questions concerning their medications. The nurse responds most
appropriately by saying:
A. "Don't worry about the medication's name if you can identify it by its color and shape."
B. "Unless you have severe side affects, don't worry about the minor changes in the way you feel."
C. "Feel free to ask your physician why you are receiving the medications that are prescribed for you."
D. "Remember that the hepatic system is primarily responsible for the pharmacotherapeutics of your
medications." - answer-C. "Feel free to ask your physician why you are receiving the medications that
are prescribed for you."
Rationale: The nurse should encourage the older adult to question the physician and/or pharmacist
about all prescribed drugs and over-the-counter drugs. The older adult should be taught the names of all
drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs.
A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for
disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with
disseminated intravascular coagulation?
1.Swelling of the calf in one leg
2.Prolonged clotting times
3.Decreased platelet count
4.Petechiae, oozing from injection sites, and hematuria - answer-1. DIC is a state of diffuse clotting in
which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because
they are consumed by the process; coagulation studies show no clot formation (and are thus normal to
prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The
presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling
and pain in the calf of one leg are more likely to be associated with thrombophebitis.
A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is
experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the
physician's orders and would question which order?
1.Prepare the client for an ultrasound
2.Obtain equipment for external electronic fetal heart monitoring
AND 1 OTHER
. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler
ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by:
1.Noting if the heart rate is greater than 140 BPM
2.Placing the diaphragm of the Doppler on the mother abdomen
3.Performing Leopold's maneuvers first to determine the location of the fetal heart
4.Palpating the maternal radial pulse while listening to the fetal heart rate - answer-4. The nurse
simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to
differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the
maternal heart rate for the fetal heart rate. Leopold's maneuvers may help the examiner locate the
position of the fetus but will not ensure a distinction between the two rates.
1.A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage
of labor when which of the following assessments is noted?
A.The client begins to expel clear vaginal fluid
B.The contractions are regular
C.The membranes have ruptured
D.The cervix is dilated completely - answer-1.4. The second stage of labor begins when the cervix is
dilated completely and ends with the birth of the neonate.
A 70-year-old client asks the nurse to explain to her about hypertension. An appropriate response by the
nurse as to why older clients often have hypertension is due to:
A. Myocardial muscle damage
B. Reduction in physical activity
C. Ingestion of foods high in sodium
D. Accumulation of plaque on arterial walls - answer-D. Accumulation of plaque on arterial walls
A 76-year-old adult female is brought to a neighborhood client after being found wandering around the
local park. The client appears disheveled and reports being hungry. Which of the following assessment
and interview findings would cause the nurse to suspect elder abuse? (Select all that apply.)
A. Falls asleep in the examination room
B. Repeatedly states, "Don't hurt me."
C. Chafing around wrists and ankles
D. Bruises in various stages of healing - answer-B. Repeatedly states, "Don't hurt me."
C. Chafing around wrists and ankles
D. Bruises in various stages of healing
A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife
prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client
that after this procedure, she will most likely have:
,1.Less pressure on her cervix
2.Increased efficiency of contractions
3.Decreased number of contractions
4.The need for increased maternal blood pressure monitoring - answer-2. Amniotomy can be used to
induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process
begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and
may increase the efficiency of contractions.
A client has been recently diagnosed with Alzheimer's disease. When teaching the family about the
prognosis, the nurse must explain that:
A. Diet and exercise can slow the process considerably
B. It usually progresses gradually with a deterioration of function
C. Many individuals can be cured if the diagnosis is made early
D. Few clients live more than 3 years after the diagnosis - answer-B. It usually progresses gradually with
a deterioration of function
A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is
transferred to the delivery room table, and the nurse places the client in the:
1.Trendelenburg's position with the legs in stirrups
2.Semi-Fowler position with a pillow under the knees
3.Prone position with the legs separated and elevated
4.Supine position with a wedge under the right hip - answer-4. Vena cava and descending aorta
compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This
leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. The best
position to prevent this would be side-lying with the uterus displaced off of abdominal vessels.
Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the
right hip provides displacement of the uterus.
A client is admitted to the birthing suite in early active labor. The priority nursing intervention on
admission of this client would be:
1.Auscultating the fetal heart
2.Taking an obstetric history
3.Asking the client when she last ate
4.Ascertaining whether the membranes were ruptured - answer-1. Determining the fetal well-being
supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention
is required.
A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3
cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is:
1.Not yet engaged
2.Entering the pelvic inlet
3.Below the ischial spines
, 4.Visible at the vaginal opening - answer-3. A station of +1 indicates that the fetal head is 1 cm below
the ischial spines.
A laboring client complains of low back pain. The nurse replies that this pain occurs most when the
position of the fetus is:
1.Breech
2.Transverse
3.Occiput anterior
4.Occiput posterior - answer-4. A persistent occiput-posterior position causes intense back pain because
of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does
not cause back pain.
A long-term care facility sponsors a discussion group on the administration of medications. The
participants have a number of questions concerning their medications. The nurse responds most
appropriately by saying:
A. "Don't worry about the medication's name if you can identify it by its color and shape."
B. "Unless you have severe side affects, don't worry about the minor changes in the way you feel."
C. "Feel free to ask your physician why you are receiving the medications that are prescribed for you."
D. "Remember that the hepatic system is primarily responsible for the pharmacotherapeutics of your
medications." - answer-C. "Feel free to ask your physician why you are receiving the medications that
are prescribed for you."
Rationale: The nurse should encourage the older adult to question the physician and/or pharmacist
about all prescribed drugs and over-the-counter drugs. The older adult should be taught the names of all
drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs.
A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for
disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with
disseminated intravascular coagulation?
1.Swelling of the calf in one leg
2.Prolonged clotting times
3.Decreased platelet count
4.Petechiae, oozing from injection sites, and hematuria - answer-1. DIC is a state of diffuse clotting in
which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because
they are consumed by the process; coagulation studies show no clot formation (and are thus normal to
prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The
presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling
and pain in the calf of one leg are more likely to be associated with thrombophebitis.
A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is
experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the
physician's orders and would question which order?
1.Prepare the client for an ultrasound
2.Obtain equipment for external electronic fetal heart monitoring
