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While observing a client’s face, which assessment finding requires immediate intervention by the nurse?

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years.The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia.

Exhibits

Nurses Notes (0700hrs): The client reports feeling increasingly short of breath over the past two days. He has a productive cough with greenish sputum. He denies chest pain but mentions feeling very fatigued. The client appears anxious and is using accessory muscles to breathe. He is sitting upright in bed and leaning forward slightly. The client states he has not been able to sleep well due to the cough. He also reports a decreased appetite over the past few days.

Physical Examination Results (0700hrs): The client is alert and oriented to person, place, and time. He has a productive cough with greenish sputum. His skin is warm and dry to the touch. Breath sounds are diminished in the lower lobes with crackles heard bilaterally. The client is using accessory muscles to breathe and has a prolonged expiratory phase. His nail beds are slightly cyanotic. The client is diaphoretic and appears fatigued.

Vital Signs (0700hrs):

• Temperature: 38.3°C (100.9°F)
• Heart Rate: 110 bpm
• Respiratory Rate: 28 breaths per minute
• Blood Pressure: 140/90 mmHg
• Oxygen Saturation: 88% on room air

Which of the following actions should the nurse take first?

The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client’s paresthesia?

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which querry should the nurse ask first?

During assessment of a client’s abdomen, the nurse observes that the client’s umbilicus is depressed and below the surface of the abdomen. Which action should the nurse take in response to this observation?

An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client’s skin for which finding?

While performing a physical assessment, the nurse is unable to palpate the client’s pedal pulses. Which action should the nurse take?

An adult male client informs the nurse that he came to the clinic to see if, “Maybe I have lung cancer or something,” and wants to get checked out since, “I can’t seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks.”. Which computer documentation of this client’s concerns should the nurse enter?