8/10/2019 34 Nclex Review

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93. The nurse is performing discharge teaching for a client with Addisonsdisease. It is MOST important for the nurse to instruct the client about

1. signs and symptoms of infection.2. fluid and electrolyte balance.

3. seizure precautions.4. steroid replacement.

Strategy: Determine the outcome of each answer choice. Is it desired?

(1) not most important

(2) not most important(3) not most important

(4) correctsteroid replacement is the most important information the client needs toknow

94. A client has a history of oliguria, hypertension, and peripheral edema.

Current lab values are: BUN 25, K+ 4.0 mEq/L. Which nutrient should be

restricted in the clients diet?

1. Protein.

2. Fats.3. Carbohydrates.4. Magnesium.

Strategy: Determine which system is involved and then determine which

nutrients need to be restricted.

(1) correctdecreased production of urea nitrogen can be achieved by restrictingprotein;

metabolic wastes cannot be excreted by the kidneys(2) decrease the nonprotein nitrogen production, these foods are encouraged

(3) decrease the nonprotein nitrogen production, these foods are encouraged(4) should not be restricted

95. After a client develops left-sided hemiparesis from a cerebral vascularaccident (CVA), there is a decrease in muscle tone. Which of the following

nursing diagnoses would be a priority to include in his care plan?

1. Alteration in mobility related to paralysis.2. Alteration in skin integrity related to decrease in tissue oxygenation.

3. Alteration in skin integrity related to immobility.4. Alteration in communication related to decrease in thought processes.

Strategy: Think about each answer choice.

(1) not a priority

(2) correctleading cause of skin breakdown is a decrease in tissue perfusion

(3) not a priority(4) would be more relevant to right-sided hemiparesis