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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?

To assess the tympanic membrane mobility, which instrument is most appropriate for the nurse to use?

 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.

A nurse has been assigned four patients, of which one of the patients has impaired immobility. Which complications should the nurse expect as a result of gout? (Select the four options that apply.)

A nurse is assessing a client's circulatory system. Which pulse site should the nurse avoid assessing bilaterally at the same time?

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?

The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)

Mrs. Britton is a 34-year-old patient who presents to the office with complaints of skin rashes. You have noted a group of lesions larger than 0.5 cm, with an elevated area of psoriasis. This is an example of a:

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve IX?

During which part of a comprehensive physical assessment would the nurse auscultate after inspecting but before percussing?

The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?