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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.)

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?

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 completing a client's history and physical examination. Which information should the nurse consider subjective data?

 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 shown on the electrocardiogram strip shown in the diagram?

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

Mr. Sprat is a 21-year-old patient who complains of nasal congestion. He admits to using recreational drugs. On examination, you have noted a septal perforation. Which recreational drug is commonly associated with nasal septum perforation?

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?

A nurse is receiving a patient from the emergency room (ER) with an admitting diagnosis of hypothyroid disorder. 

Admitting diagnosis

acute hypothyroid disorder

Physician order

Synthroid 0.1 mg po daily

The receiving medical- surgical nurse would expect the patient to exhibit which signs and symptoms? Select all that apply

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