SNA NCLEX Prep - teams

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

• Lemon sherbet

• Plain yogurt

• Cranberry juice

• Carrot juice

Answer explanation

Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice.

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response?

• Hypotension

• Numbness

• Shivering

• Reduced blood viscosity

Answer explanation

Shivering is a systemic response to cold therapy as the body attempts to promote heat production.

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

• Temperature

• Fetal heart rate (FHR)

• Bowel sounds

• Respiratory rate

Answer explanation

Magnesium sulfate is typically administered to a client in preterm labor to achieve the tocolytic (uterine relaxation) effect. Magnesium sulfate depresses the function of the central nervous system, causing respiratory depression. Baseline assessment of respiratory status, checking the respiratory rate frequently, and reassessment of respiratory status with each change in dosage of magnesium sulfate is the primary focus when assessing the client. There is a narrow margin between what is considered a therapeutic dose and a toxic dose of magnesium sulfate.

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

• Placing the newborn on a warm surface

• Preventing air drafts

• Drying the newborn’s skin thoroughly

• Maintaining ambient room temperature at 24° C (75° F)

Answer explanation

Heat loss through evaporation occurs when moisture on the skin is converted to a vapor. This process is the most significant cause of heat loss in the first few days of life but is minimized by quickly and thoroughly drying the infant

A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?

• Agranulocytosis

• Neuroleptic malignant syndrome

• Akathisia

• Tardive dyskinesia

Answer explanation

Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse effect of antipsychotic medications that requires emergency medical intervention. Manifestations of NMS are sudden and include changes in level of consciousness, seizures, and stupor.

A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

• Hyperactive bowel sounds

• Bradycardia

• Hypertension

• Dental erosion

Answer explanation

Complications of anorexia include bradycardia and muscle wasting.

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.)

• Alopecia

• Tremors

• Moon face

• Purple striations

• Buffalo hump

Answer explanation

Alopecia is correct. Clients who have Cushing's syndrome can develop hirsutism, which is excessive body hair. Women can also develop alopecia, in the form of male pattern baldness.

Tremors is incorrect. Tremors are not a common manifestation of Cushing's syndrome.

Moon face is correct. Moon face, which is manifested by a round, red, full face, is a common manifestation of Cushing's syndrome.

Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are common manifestations of Cushing's syndrome.

Buffalo hump is correct. Buffalo hump, which is a collection of fat between the shoulder blades, is a common manifestation of Cushing's syndrome.

A nurse is providing teaching to a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates an understanding of the teaching?

• "I should increase my caffeine intake."

• "I will take my duloxetine in the morning, so I have more energy to accomplish tasks."

• "Low-impact aerobics can help reduce episodes of pain."

• "A course of chemotherapy treatment should provide a cure."

Answer explanation

The nurse should reinforce that clients who have fibromyalgia can help reduce pain through regular low-impact aerobics, such as walking, swimming, and biking.

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

• Elevating her feet

• Massaging her legs

• Flexing her ankles

• Ambulating soon after surgery

Answer explanation

Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?

• Bananas

• Cooked carrots

• Cheddar cheese

• 2% milk

Answer explanation

The nurse should determine that bananas are the best food source to recommend because 1 cup of bananas contains 806 mg of potassium. In addition to the potassium supplements the provider might prescribe, the client should increase his daily intake of foods that have high potassium content, such as bananas, orange juice, and spinach.