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A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which adventitious breath sounds?

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

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 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.)

A nurse is caring for a client in an assisted living facility who has vision problems.

Medical history 

A 68-year-old woman with complaints of having trouble reading the paper, sewing, and even seeing the faces of her grandchildren up close.

Nurse's notes

The client was noted to have some loss of nearsightedness

Complete the sentence by using the list of options.The findings noted by the health care practitioner suggest that

The nurse reviews the arterial blood gas results of a client and notes the following:  

pH 7.45, [normal range: 7.35-7.45]  

Paco2 of 30 mm Hg (30 mmol/L), [normal range: 35-45]  

HCO3- of 20 mEq/L (20 mmol/L), [normal range: 22-26]  

Which condition would the nurse analyze these results to indicate?

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 is precepting a nursing student. The nurse explains to the nursing student how you would perform the graphesthesia test on a client. What is the correct way to perform this test?

A nurse in an emergency department is caring for a client who has abdominal pain.

Nurses' Notes 

0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk."

0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily.

0915: Fecal mass of hard, dry stool removed digitally from client per provider's order.

1015: Provided teaching to client and partner about constipation and methods to avoid further impaction.

Diagnostic Results

0900:

Abdominal x-ray: Large amount of fecal material throughout the colon with rectal impaction. No evidence of small bowel obstruction.

A nurse is providing teaching to a client who has constipation. Which information should the nurse include? (Select all that apply.)

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods that should be avoided. Which food should the nurse encourage the client to avoid?

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves?