Take full exam for free

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

The nurse performs a two-point discrimination test by applying two sterile needles lightly to the fingertips and moving the needle tips in ever-closing distances. A middle-aged adult client senses two points at a distance of 3 mm on the fingertips and 10 mm on the palms of the hands. Which interpretation of this finding is accurate?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

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?

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

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?

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

A nurse is caring for a 45-year-old male client in the emergency department who sustained a fall from a ladder. The client has a closed and displaced fracture of the right ulna and radius. The nurse is monitoring the client closely for any changes in condition.

Exhibits

Nurses’ Notes (0800 hrs)

• The client is alert and oriented to person, place, time, and situation.
• The right forearm is visibly deformed with significant swelling and bruising.
• The client reports severe pain rated 10/10, described as sharp and throbbing.
• Capillary refill in the right hand is 4 seconds.
• The skin on the right forearm is warm to the touch.
• Radial pulse is 2+ and palpable.
• The client denies any numbness or tingling in the right hand.

Vital Signs (0800 hrs)

• Temperature: 37.2°C (99°F)
• Heart Rate: 88 bpm
• Blood Pressure: 138/82 mmHg
• Respiratory Rate: 18 breaths/min
• Oxygen Saturation: 98% on room air

Diagnostic Results (0800 hrs)

• X-ray results: Closed and displaced fracture of the right ulna and radius.
• Hemoglobin: 13.5 g/dL (Reference range: 13.8-17.2 g/dL)
• White Blood Cell Count: 8,000/mm³ (Reference range: 4,500-11,000/mm³)

Provider’s Prescriptions (0800 hrs)

• 0.9% sodium chloride IV infusion at 75 mL/hr
• Morphine sulfate 2 mg IV push STAT once
• Obtain cast cart
• Neurovascular assessment every hour for the first 24 hours

A nurse is caring for a 45-year-old male client in the emergency department with a closed and displaced fracture of the right ulna and radius. Based on the exhibits provided, what is the priority nursing action at this time?

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

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