NCLEX Questions

When instructing a patient with Addison's disease about nutrition, which of the following diet modifications is NOT recommended? 1. a diet w adequate caloric intake 2. a high protein diet 3. a restricted sodium diet 4. a diet high in grains

3, A patient with Addison's disease (adrenal insufficiency) requires normal dietary sodium to prevent excess fluid loss and maintain electrolyte balance. Adequate caloric intake is recommended with a diet high in protein and complex carbohydrates, including grains.

When measuring an adult client's apical heart rate, where does the nurse place the stethoscope? 1. third left intercostal space at midclavicular line 2. fourth left intercostal space at midclav. line 3. fifth left intercostal space at midclab. line 4. second left intercostal space at midclav. line

3, FILM = Fifth Intercostal Midclavicular Line. The apical pulse is auscultated with a stethoscope over the chest where the heart's mitral valve is best heard. For adults, the point of maximum pulse is the fifth left intercostal space at the midclavicular line. In infants and young children, the apical pulse is located at the fourth intercostal space at the left midclavicular line

An end-stage renal failure client has opted for an arteriovenous (AV) fistula for long-term treatment by hemodialysis. Following the surgical creation of the AV fistula, how long until the client can begin hemodialysis? 1. 2-3 weeks 2. 2-3 months 3. 4-6 weeks 4. 4-6 months

2, An AV fistula is a connection, made by a vascular surgeon, of an artery to a vein. An AV fistula frequently requires 2 to 3 months to develop, or mature, before the patient can use it for long-term hemodialysis

Of the following positions, which one facilitates maximum air exchange? 1. Lithotomy 2, High Fowler's 3. Orthopneic 4. trendelenburg

3. Orthopneic (sitting in a leaning position) allows for the most lung expansion. High Fowler's can help, but is not as effective as the orthopneic position. Trendelenburg is used for hypotension or low cardiac output. Lithotomy is used for vaginal examinations and childbirth.

The nurse does an admit for a client with a diagnosis of pleural effusion. When doing a respiratory assessment for this client, the nurse will determine if the client has 1. increased bronchial breath sounds on the affected side. 2. increased percussion sounds at the area of effusion. 3. decreased respiratory rate and use of accessory muscles. 4. decreased chest expansion on the affected side.

4, A pleural effusion is a collection of fluid between the pleural layers of the lung. The fluid prevents chest expansion on the affected side. Respiratory rate increases and use of accessory muscles can be observed. Breath sounds are decreased since ventilation on the affected side is also decreased. Resonance is dull and flat to percussion.