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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?

The nurse is working with a group of clients. Which clients are at risk for developing skin cancer? Which assessment findings are at risk for skin cancer (Select all 3 that apply)?

A nurse is teaching about the risk factors of developing a stroke with a group of older adult clients. Which nonmodifiable risk factors should the nurse include in the teaching?

Which technique would the nurse use to perform scoliosis screening in a school-age child?

What is the rate on the rhythm strip in the image below?

A nurse is caring for a postoperative client. The nurse should base the client's pain management interventions primarily on which methods of determining the intensity of the client's pain?

The nurse reviews the arterial blood gas results of an assigned client and notes the laboratory report results

pH of 7.30, [normal pH is 7.35 to 7.45]

Paco2 of 58 mm Hg, [Normal Paco2 is 35 to 45 mm Hg]

Pao2 of 80 mm Hg. [normal is 80-100]

HCO3 of 27 mEq/L (27 mmol/L). [Normal HCO3 is 22-26]

The nurse interprets that the client has which acid-base disturbance?

A nurse is interpreting the ECG strip of a client who has bradycardia. Which cardiac components should the nurse identify as the role of the P wave?

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 nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which manifestations?

 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.