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The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival?

Ace inhibitors/ lisinopril

A female client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia?

Acromegaly

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium.

A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention?

Assess for signs of injury

A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean?

Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

Which assessment parameter is important for the client diagnosed with congestive heart failure?

Distended veins

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? Use all options.

Inspection Auscultation Percussion Palpation

A nurse is caring for a client with an abnormally low blood glucose concentration. What glucose level should the nurse observe when assessing laboratory results?

Less than 70 mg/dL (3.7 mmol/L)

A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?

Maintain the client in a semi-Fowler's position

A client with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the client's care plan?

Protective isolation and vigilant use of standard precautions

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

The client lying in a lateral position, with the head of bed flat

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client?

Use an electric razor when assisting client with shaving

The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem?

air leak

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

encourage coughing and deep breathing.

An older male client with a history of chronic laryngitis reports a persistent hoarseness. What condition is the client at risk to develop?

laryngeal cancer

A female client is being successfully treated for Cushing's syndrome. The nurse should expect a decline in:

serum glucose level.

Select the assessment finding that the nurse should immediately report, post radical neck dissection.

stridor

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?

wheezes with wet lung sounds

The admissions department at a local hospital is registering a 78-year-old client for an outpatient diagnostic test. The admissions nurse asks if the client has an advance directive. The client reportsnot wanting to complete an advance directive because they do not want anyone controlling theirfinances. What would be appropriate information for the nurse to share with this client?

"Advance directives are limited only to health care instructions and directives."

A client is taking glyburide (DiaBeta), 1.25 mg P.O. daily, to treat type 2 diabetes. Which statement indicates the need for further client teaching about managing this disease?

"I skip lunch when I don't feel hungry."

A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what?

"I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours."

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?

"Maintain a high-carbohydrate, low-fat diet.

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

"Test your blood glucose every 4 hours."

The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining?

1 L

A client with Parkinson's disease is prescribed amantadine hydrochloride 100 mg twice a day. The pharmacy supplies amantadine syrup, because the client has a history of difficulty swallowing tablets. The label reads 50 mg/5 mL. How many milliliters would the nurse administer to the client for each dose? Enter the correct number ONLY.

10

A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer:

15 to 20 g of a fast-acting carbohydrate such as orange juice.

The nurse is assisting the client to manage the cardiovascular risk factors of hyperlipidemia and hypertension. The client asks the nurse what type of a diet would be best to follow. What is the best response by the nurse?

A diet low in sodium, fat, cholesterol

The nurse is caring for a 90-year-old client who has never completed an advance directive. The client has a child but has not seen the child in several years. A neighbor has assisted the client with meals and housecleaning for many years. The neighbor states that the client expressed only wanting to have comfort measures. The estranged offspring wants the client to be treated aggressively. Which would be the nurse's initial step?

Assess the client's ability to state wishes.

A client is ordered continuous bladder irrigation at a rate of 60 gtt/minute. The nurse hangs a 2 L bag of sterile solution with tubing on a three-legged IV pole. She then attaches the tubing to the client's three-way urinary catheter, adjusts the flow rate, and leaves the room. Which important procedural step did the nurse fail to follow?

Evaluating patency of the drainage lumen

A nurse should perform which intervention for a client with Cushing's syndrome?

Explain that the client's physical changes are a result of excessive corticosteroids

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?

Help the client sit upright when eating and feed slowly

The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician?

High epigastric pain and/or discomfort

The nurse is caring for a client who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the client?

How to splint the incision when coughing

Which may be a potential cause of hypoglycemia in the client diagnosed with diabetes mellitus?

The client has not eaten but continues to take insulin or oral antidiabetic medications.

A nurse is assessing a client who has diabetes for the presence of peripheral neuropathy. The nurse should question the client about what sign or symptom that would suggest the possible development of peripheral neuropathy?

The presence of a tingling sensation

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason?

To reduce gastric and pancreatic secretions

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium (Tensilon) test.

The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to

refrain from eating or drinking for now.

The nurse is providing care to a client who has had a transurethral resection of the prostate. The client has a three-way catheter drainage system in place for continuous bladder irrigation. The nurse anticipates that the catheter may be removed when the urine appears as which of the following?

Light yellow and clear

After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?

The client reports bladder spasms and the urge to void.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?

Measure blood glucose concentration every 4 to 6 hours

The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about?

Methotrexate

A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention?

Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential

Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia?

Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.

The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to?

Orthopnea

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?

Tension pneumothorax

A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find:

deposits of adipose tissue in the trunk and dorsocervical area.