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A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?

A nurse is caring for a client who has a body mass index (BMI) of 26. The nurse should place the client in which BMI category?

A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?

 A nurse in an emergency department (ED) is admitting a client.

Vital Signs 

1000:

Temperature 38.6° C (101.5° F)

Heart rate 106/min

Respiratory rate 26/min

Blood pressure 110/54 mm Hg

Oxygen saturation 94% on room air

Nurses Notes 

1000:

Client presents to ED with report of shortness of breath for 3 days, with headache, chills, fever, sore throat, and cough.

Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.

Client's face is flushed, sinus tachycardia, rate of 106/min, $152 heart sounds heard on auscultation. Pulses palpable.

Breath sounds with crackles to right lower lobe, tachypnea, rate of 26/min. Tactile fremitus and decreased lung expansion noted upon assessment. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up."

Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."

Reports decreased urination in the past day.

Client reports they have not had a pneumococcal vaccine. States, "1 Just hate needles."

Diagnostic Results

1030:

Chest x-ray.

Areas of increased density and white infiltrates to lower right lobe.

Select 3 objective findings in the client's medical record that may be indicative of pneumonia.

How should the nurse interpret the rhythm depicted in the image?

How should the nurse identify the rhythm shown in the diagram?

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which assessment data is an expected finding?

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item?

A nurse is assessing a client who reports taking a medication that causes increased urination resulting in dehydration for the past 3 days. Which findings should the nurse expect in a client who is dehydrated? (Select all that apply.)

When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. When the client performs this maneuver, the nurse is testing what?

A patient with a history of duodenal ulcer is admitted to the emergency department with reports of pain. The nurse should assess for this pain by palpating in which abdominal quadrant?