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A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following:

- pH is 7.12 (normal range: 7.35-7.45)

- PaCO2 is 90 mm Hg (normal range: 35-45)

- HCO3- is 22 mEq/L (normal range: 22-26)

The nurse interprets the results as indicating which condition?

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?

A nurse is preparing a program on osteoporosis for a local women's group. Which of the findings does the nurse recognize as a modifiable risk factor?

The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session? (Select all that apply.)

Which lung sounds are expected? (Select all that apply.)

 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 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 a patient is unable to see objects at a distance, which term is used to document this finding?

When hearing is evaluated, which cranial nerve is being tested?

While performing an abdominal assessment on a patient, the nurse notes an abdomen shape similar to the rounded abdomen only greater. This contour is anticipated in pregnancy and seen in adults with ascites and obesity. What term should the nurse use to document this finding?