NCLEX-RN
Health Care of the Older Adult NCLEX Questions
Extract:
Question 1 of 5
During cardiopulmonary resuscitation (CPR), the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for injury with compression over the xiphoid process?
Correct Answer: B
Rationale: Compressing the xiphoid process risks liver injury, as it lies directly beneath, potentially causing laceration or hemorrhage.
Question 2 of 5
Which of the following is significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
Correct Answer: A,C,E
Rationale: Breath sounds (
A) indicate lung involvement. Chest pain (
C) may signal pleurisy or complications. Nail bed color (E) reflects oxygenation. Bowel sounds and peripheral edema are less relevant to pneumonia assessment.
Question 3 of 5
During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room?
Correct Answer: C
Rationale: During leukemia induction therapy, the client is immunocompromised, and scented items like a lavender sachet may harbor bacteria or cause allergic reactions. A Bible, picture, and hairbrush (if clean) are safe and support emotional well-being.
Question 4 of 5
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.
Question 5 of 5
A 36-year-old female is scheduled to receive external radiation therapy and a cesium implant for cancer of the cervix. Which of the following statements would be most accurate to include in the teaching plan about the potential effects of radiation therapy on sexuality?
Correct Answer: B
Rationale: Vaginal dryness is a common side effect of cervical radiation due to mucosal changes, and should be included in the teaching plan to prepare the client.