Basic Physical Exam

The nurse is performing a newborn assessment on a neonate in the childbirth suite. The nurse notes epispadias. Which documentation of the defect would the nurse note?

C

The nurse is preparing the prescribed fentanyl 25 mcg I.V. After obtaining a fentanyl 50 mcg/ml vial, what is the priority action by the nurse?

Draw 0.5 ml medication into a syringe, draw the remaining 0.5 ml into another syringe, and ask another nurse to witness the waste of 0.5 ml into the sink.

A nurse observes a student auscultating a client's lungs. Which action by the student indicates a need for further instruction on respiratory assessment skills?

The student places the stethoscope over the posterior chest and only listens during inspiration.

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated?

applying an external fetal monitor and completing a physical assessment

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site?

carotid

A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed?

Level of consciousness, pain level, and wound dressing

A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client?

broth, gelatin cubes, and tea

What are important nursing responsibilities when a referral to other health team members has been made for a client?

sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living

The nurse is caring for a client who has become unresponsive. The blood pressure is 80/40 mm Hg, and SpO2 is 90% on 50% face mask. What should the nurse do next?

Call the rapid response team.

Which of the following sounds should the nurse expect to hear when percussing a distended bladder?

Dullness.

A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate?

ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel

A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time?

Obtain vital signs.

A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

The client's pulse and respiratory rates increased moderately during ambulation.

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. What should the nurse do?

Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results.

The nurse takes the blood pressure of a preschool child. To determine if the blood pressure is normal, the nurse compares the results to percentiles for systolic and diastolic blood pressure. What other information does the nurse need to interpret the blood pressure? Select all that apply.

age gender height

A nurse, driving on a highway, is the first on the scene after a multivehicle collision. Which assessment data for the accident victims would require immediate care?

head injuries

In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment?

health habits, family relationships, affect, and thought patterns

An older adult client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking properly. Upon physical assessment, the nurse notes tachycardia, hypotension, and hyperthermia. Which admission order would the nurse implement first?

intravenous fluid hydration

The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration?

orthostatic hypotension

During a routine otoscopic examination the nurse identifies these assessment changes. Which finding requires additional action?

reddened tympanic membrane without discomfort

A client is drinking 3000 mL of fluid a day during the acute phase of kidney failure. Which of the following would be an expected assessment finding?

straw-colored urine

A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should

use the bell of the stethoscope.

The nurse is working in the intensive care unit with a client in shock. During hand-off the nurse reports the results of which assessment findings that signal early signs of the decompensation stage? Select all that apply.

vital signs skin color urine output peripheral pulses

Which of the following observations by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?

formula in the client's mouth during the feeding, and increased cough

The nurse is unable to palpate the client's left pedal pulses. What should the nurse do first?

Use a Doppler ultrasound device.

A client asks the nurse why the prostate-specific antigen (PSA) level is determined before the digital rectal examination. What should the nurse tell the client?

"A prostate examination can possibly increase the PSA."

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma?

"At first, the stoma may bleed slightly when touched."

To evaluate a client's cerebellar function, a nurse should ask

"Do you have any problems with balance?"

Which assessment question is most likely to yield clinically meaningful data about a female client's sexual identity?

"How do you feel about yourself as a woman?"

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding?

"I should drink more water when feeling thirsty or becoming irritable."

A nurse is performing a preoperative assessment. Which client statement should alert the nurse to the presence of risk factors for postoperative complications?

"I've cut my smoking down from two packs to one pack per day."

The nurse is preparing a client for a cardiac catheterization. Which client statements would the nurse need to report to the health care provider immediately?

"I took my metformin this morning."

The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative?

"Just as I get over a virus, it seems that I get another."

A nurse is assessing a client who has a rash on the chest and upper arms. Which questions would the nurse ask in order to gain further information about the client's rash? Select all that apply.

"When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "What have you been using to treat the rash?" "Have you recently traveled outside the country?"

The nurse is preparing to administer lorazepam 1 mg I.V. for a client with anxiety. The available dose is 2 mg/2 ml vial. How many milliliters of medication will the nurse ask another nurse to witness as a waste? Record your answer as a whole number.

1

When assessing the client's level of consciousness following moderate sedation, what would be the appropriate Glasgow Coma Scale score for a client who opens the eyes when the nurse says the client's name, answers questions but is confused, and is able to obey commands and move all extremities?

13

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?

28 breaths/min and audible

Which of the following statements heard during shift report identifies an important priority for action?

A postoperative client's pulse has been increasing, and the blood pressure is decreasing.

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. What should the nurse do first?

Take the client's blood pressure.

The nurse is co-assigned with a licensed practical/vocational nurse (LPN/VN) to care for 20 clients on a skilled, long-term care facility. When working as a team, which nursing duties would the nurse delegate to the LPN/VN? Select all that apply.

Administer morphine sulfate 30 mg intramuscular every 4 hours as needed. Place a nasogastric tube for gastric decompression. Calculate output every 8 hours and report to the health care provider. Insert a 20 French Foley catheter.

Which is the highest priority action by the nurse before completing this skill?

Assess stomach residual.

A client has had hoarseness for more than 2 weeks. What should the nurse do?

Assess the client for dysphagia.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

Assess the client's level of pain, and administer prescribed analgesics.

The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action?

Assess the client's temperature.

The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. What should the nurse do first?

Call the rapid response team (RRT)/medical emergency team.

The nurse in the postanesthesia care unit notes that one of the client's pupils is larger than the other. What should the nurse do next?

Check the client's baseline data.

The surgical floor receives a client from the postanesthesia care unit. Ten minutes ago, the final assessment in the postanesthesia care unit indicated that the client had a patent airway and stable vital signs. The client's pain level was 2. What should the nurse do next?

Check the dressing for signs of bleeding.

A cloth chest restraint has been presecribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client?

Check the extremities for circulation based on hospital protocols.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring.

While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which would be most important for the nurse to do?

Ensure that the room is kept warm.

A client reports a pain level of 8 on a scale of 0 to 10. Which is the nurse's best action?

Further assess the pain.

The nurse is participating in a blood pressure screening event. After three separate readings taken at least 2 minutes apart, the nurse determines that a client has a blood pressure of 160/90 mm Hg. What should the nurse advise the client to do?

Have blood pressure evaluated within 1 month.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first?

Institute droplet precautions.

The client is admitted to the hospital to rule out duodenal ulcer. The nurse performs the admission history. Which description(s) of pain would be most characteristic of a duodenal ulcer? Select all that apply.

Knawing pain after food intake. Left epigastric pain that awakens the client.

The nurse notices that the client's temperature over the past 24 hours has risen from 98.8°F (37.1°C) to 101.6°F (38.7° C). The nurse completes a head to toe assessment and documents the nurse's note. What would be the nurse's next nursing action?

Notify the health care provider.

An adult male client has been unable to void for the past 12 hours. What is the best method for the nurse to use when assessing for bladder distention in a male client?

Palpate for a rounded swelling above the pubis.

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action?

Palpate for the bladder above the symphysis pubis.

Why should the nurse avoid palpating both carotid arteries at one time?

Palpating both arteries at one time may cause severe bradycardia.

After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention?

Perform a bladder scan, and obtain an order for urinary catheterization.

A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation?

Respect the adolescent's wishes and maintain her confidentiality.

When taking a client's vital signs on the first postoperative day, the unlicensed assistive personnel (UAP) reports to the nurse that the oral temperature is 100° F (37.8° C). After encouraging the client to use the incentive spirometer, the nurse should delegate which activity to the UAP?

Place a hyperthermia blanket on the client's bed.

The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do next?

Promptly assess the client for potential perforation.

After suctioning a client with a tracheotomy tube, the nurse performs an assessment to determine the effectiveness of the suctioning. Which findings indicate that no further interventions are needed?

Respiratory rate drops from 24 breaths/minute to 16 breaths/minute.

The nurse is monitoring a very drowsy client in the immediate postprocedure phase of moderate sedation. The client will open the eyes to repeated verbal stimulation but does not respond verbally. The nurse has an order to give an antiemetic that is known to cause sedation. What assessment tool should the nurse utilize for this client?

Richmond Agitation-Sedation Scale (RASS)

A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. What instructions should the nurse give the client?

Take her temperature at the same time every morning before getting out of bed.

A client from Mexico has bacterial pneumonia and has a temperature of 102°F (39°C). The client has been treating the infection by drinking milk. How should the nurse interpret the client's method of self-treatment?

The client is using the hot disease concept.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control?

The client exhibits signs of adequate GI perfusion with normal bowel sounds.

The nurse is caring for a client with a head injury. Which client goal is most appropriate for the acute phase of a neurological injury?

The client's vital signs will stabilize, returning to normal range.

A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease?

The lump is round and movable.

Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's postprocedure status. Which outcome is expected?

There is no bleeding at the aspiration site.

The charge nurse on a pediatric unit is making clientnassignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?

a 4-year-old with chronic graft-versus-host disease who is incontinent

The emergency department (ED) nurse should assess which client first?

a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain

The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment?

a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client?

a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance

The nurse receives morning lab work after shift hand-off. Based on the analysis of lab values, which client would the nurse assess first?

a client diagnosed with renal disease and a serum potassium level of 6.1 mEq/dL (6.1 mmol/L) who has limited output

Which client should the nurse assess first?

a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain

After administering prescribed medications to clients, which client requires immediate intervention?

a client taking digoxin who has a morning potassium level of 3.0 mEq/L

The charge nurse is working on a medical-surgical unit and must rearrange room assignments for several clients. Which clients should the nurse put in the same room? Select all that apply.

a client who underwent cholecystectomy today a client with pain related to pancreatitis

A nurse is working in the intermediate care unit. After receiving change of shift report who should the nurse assess first?

a client with aortic stenosis who has a blood pressure of 84/52 mm Hg

An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply.

acute respiratory distress syndrome pneumonia pulmonary edema

A client's face, neck, and chest have been burned in a fire 1 hour ago. What is the nurse's priority assessment at this time?

airway obstruction

The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition?

allergies

Which factors are major components of a client's general background history?

allergies and socioeconomic status

When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply.

allergies to any medications allergies to items other than medications, such as foods and animals reaction to the allergen severity of the allergy

A client, age 75, is admitted to the hospital. Because of the client's age, how should the nurse modify the client's assessment?

allowing extra time for the assessment

A client in surgery has an endotracheal tube (ET) in place. The nurse should call a time-out if which requirements are not in place? Select all that apply.

an identification band an IV line oxygen administration an anesthetist/anesthesiologist

For which client is the nursing assessment of pain most likely to result in undertreatment?

an older adult who grimaces and states no pain after a gastrostomy tube placement

The nurse is monitoring a client who is recovering from moderate sedation. What are normal assessment findings in the immediate postprocedure phase? Select all that apply.

briefly opens eyes when the nurse says the client's name able to maintain oxygen saturation of 96%

The nurse is caring for a 1-month-old infant who fell from the changing table during a diaper change. Which signs and symptoms of increased intracranial pressure (ICP) is the nurse likely to assess in a 1-month-old infant? Select all that apply.

bulging fontanels high-pitched cry irritability

The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. What should the nurse assess?

changes from the normal expected findings

A client is transferred to the acute stroke unit. The nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care and is aware this information indicates what regarding a client's clinical status?

changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person

The nurse notes serous discharge when an abdominal dressing is changed. The nurse would document this drainage as which of the following?

clear, watery, yellow-tinged drainage

An older adult reports being cold in the room even though the thermostat is set at 75°F (24°C). The nurse can tell the client that older adults may feel cold for which reason?

decreased ability to thermoregulate.

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include

delayed gastric emptying.

A client who was involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client was hit in the right temporal lobe. What abnormalities would the nurse expect the client to demonstrate? Select all that apply.

difficulty comprehending language decreased hearing amnesia for recent events

On the 2nd day after surgery, the nurse assesses an older adult client. The nurse finds: blood pressure is 148/92 mm Hg. heart rate is 98 bpm. respirations are 32 breaths/min. O2 saturation is 88% on 4 L/min of oxygen administered by nasal cannula. breath sounds are coarse and wet bilaterally with a loose, productive cough. The client has voided 100 mL very dark, concentrated urine during the last 4 hours. bilateral pitting pedal edema. Using the SBAR (Situation-Background-Assessment-Recommendation) method to notify the health care provider of current assessment findings, the nurse should recommend which prescription?

diuretic medication

The nurse is assessing a client's testes. Which finding indicate the testes are normal?

egg-shaped

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?

every 15 minutes

The nurse is assessing the client's bowel sounds (see the accompanying image). The nurse should:

expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds.

A nurse is caring for a group of clients. After receiving shift report, the nurse should make rounds on the clients in which order? Place in order of the highest to lowest priority. All options must be used.

female client who is 34 years of age and just returning from the recovery room following an abdominal hysterectomy; IV running at 50 drops per minute with 100 mL remaining client who is 79 years of age 2 days post surgery for removal of cancer of the colon who has had a tracheotomy for 4 years client who is 75 years of age with a fractured hip of 4 days who needs to be turned frequently client who is 50 years of age and diagnosed with diabetes mellitus 3 days ago who is learning to administer insulin

There has been a fire in an apartment building, and it has spread to seven apartment units. Victims have suffered burns, minor injuries, and broken bones from jumping from windows. Which persons can be safely treated at the scene and transported to a health care facility after victims with more emergent problems have been transported first? Select all that apply.

female client who is 5 months pregnant with no apparent injuries child client who is 10 years of age with an apparent simple fracture of the humerus female client who is 20 years of age with first-degree burns on hands and forearms

Which plane divides the body longitudinally into anterior and posterior regions?

frontal plane

The nurse is completing a sexual history on a client. The client reports a history of having a sexually transmitted infection (STI) that lies dormant in the body and can reoccur, but does not remember the name. Which STI matches the client's description?

herpes

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding?

high pitched gurgling noises in four abdominal quadrants

Which of the following findings would be expected in a client with chest trauma, rib fractures, and respiratory acidosis?"

hypoventilation due to inability to take deep breaths because of pain

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem?

ineffective breathing pattern

A nurse is assessing a client's abdomen after abdominal surgery. Place the assessment techniques in the order in which the nurse should conduct them. All options must be used.

inspection auscultation percussion palpation

The nurse is obtaining a health history from a client of Puerto Rican descent. Which is most likely to be a health problem with a cultural connection for this client?

lactose enzyme deficiency

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect

left calf circumference 1" (2.5 cm) larger than the right.

The nurse is assessing the client's umbilicus (see the accompanying image). The nurse should document the umbilicus as being:

midline.

The most appropriate way for the nurse to assess a client's ability to perform activities of daily living is to: observe client performing varied activities of daily living.

observe client performing varied activities of daily living.

A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities?

obtaining a rubella titer on a woman who is planning to start a family

When assessing a dark-skinned client for cyanosis, what area of the body will best reveal cyanosis?

oral mucous membranes

A client has a nursing diagnosis of fluid volume deficit. Which of the following nursing assessment findings would support this diagnosis?

orthostatic blood pressure changes

A nurse is caring for a client during barbiturate therapy. The client receiving this drug should be evaluated for which of the following?

physical dependence

The family of a hospice client calls the agency to report that the client passed away while sleeping during the night. What should the nurse expect when arriving to assess the client?

pooling of blood in the sacrum

When teaching a group of middle-aged women, what would the nurse include when discussing primary prevention?

prevention of osteoporosis, the importance of regular breast self-examinations, and Pap smears

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are

progressively deeper breaths followed by shallower breaths with apneic periods.

After a local factory explodes, a nurse begins to triage the victims. Victim 1 is unconscious and not breathing. After opening the victim's airway, the victim resumes spontaneous respirations at a rate of 18 and has a capillary refill time of less than 2 seconds but remains unconscious. What color tag should the nurse use for this victim?

red

Which finding in a client who recently underwent a total hip replacement would require a nurse to take immediate action?

red painful area on the calf of the affected leg

When percussing a client's chest, what should the nurse expect to hear?

resonance

A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate:

respiratory acidosis.

The nurse is assessing a client's activity tolerance. Which report from a treadmill test indicates an abnormal response?

respiratory rate decreased by 5 breaths/minute

An elderly client admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the laboratory results (see accompanying chart). Which of the abnormal lab values is consistent with the client's symptoms?

serum sodium

A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment?

signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes

The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessments? Select all that apply.

suicide or self-harm ideation recent use of substances of abuse allergic reactions or adverse drug reactions

A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit their head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that the client has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain?

temporal

When examining a client who has abdominal pain, a nurse should assess

the symptomatic quadrant last.

A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest?

thrombophlebitis

A client of African descent is brought to the emergency department after sustaining injury in a vehicle accident. The client is bleeding profusely from the wounded leg. In which area would the nurse check for pallor in the client?

tongue

A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis?

tripod position

The nurse is caring for a client that had surgery this morning. What assessment finding would the nurse notify the health care provider about?

urinary output of 20 mL/hr over 2 hours

A nurse is performing an assessment on an adult with hypertension who falls into the middle-old elderly population. Which findings would be reported to the health care provider?

urine output of 600mL/24 hours

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention?

urine output of 90 mL over the past 6 hours

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?

vesicle

A client tells a nurse that about a rash on the back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions?

vesicles

The nurse is caring for an infant who is retaining fluid. How will the nurse assess for urine output?

weighing the diaper before and after micturition

A nurse is observing a unlicensed assistive personnel (UAP) measure a client's blood pressure. Which action by the UAP would be evaluated as correct?

wrapping the cuff around the limb, with the bladder covering three-quarters of the limb circumference