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

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?

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

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client’s use of illegal drugs and alcohol?

To objectively confirm the presence of fever, before taking the client’s temperature, which action should the nurse take?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

When evaluating a client’s rectal bleeding, which findings should the nurse document?

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?

While auscultating a client’s abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

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?