Basic Physical Assessment

A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding? pulse pressure pulse deficit pulse rhythm pulsus regularis

pulse deficit

The nurse is assessing a client's testes. Which finding indicates the testes are normal? soft egg-shaped spongy lumpy

egg-shaped

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? "The stoma should appear dark and have a bluish hue." "At first, the stoma may bleed slightly when touched." "The stoma should remain swollen distal to the abdomen." "A burning sensation under the stoma faceplate is normal."

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

A nurse can auscultate for heart sounds more easily if the client is supine. on his right side. holding his breath. leaning forward.

leaning forward.

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 slight nontender edema in the nonaffected leg ecchymosis around the incision site three episodes of emesis in the past hour

red painful area on the calf of the affected leg

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 face hands abdomen

tongue

A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse? "Are you having pain in your leg?" "Tell me what you are feeling." "Do you need pain medication?" "Are you feeling all right?"

"Tell me what you are feeling."

Which statement heard during shift report identifies an important priority for action? A client is reluctant to ambulate on the evening of surgery. A postoperative client's pulse has been increasing, and the blood pressure is decreasing. A postoperative client is drowsy and slow to respond when the analgesic is at its maximal effect. A postoperative client has not voided for 5 hours after surgery.

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

A nurse is performing a preoperative assessment. Which client statement should alert the nurse to the presence of risk factors for postoperative complications? "I haven't been able to eat anything solid for the past 2 days." "I've never had surgery before." "I had an operation 2 years ago, and I don't want to have another one." "I've cut my smoking down from two packs to one pack per day."

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

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? "Are you having pain?" "Is the pain constant?" "How does the pain medication make you feel?" "What does the pain feel like?"

"What does the pain feel like?"

The nurse is assessing a client who has had hoarseness for more than 2 weeks. What action should the nurse take? Refer the client to a health care provider for a prescription for an antibiotic. Instruct the client to gargle with salt water at home. Assess the client for dysphagia. Instruct the client to take a throat analgesic.

Assess the client for dysphagia.

The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, their pulse is 120 bpm, and their blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. What should the nurse do first? Call the PACU. Call the health care provider (HCP). Call the respiratory therapist. Call the rapid response team (RRT)/medical emergency team.

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

A nurse is assessing a postoperative client. Which information would the nurse document as subjective data? Client reports incisional pain as a level 3 on a pain scale of 1-10. Client's pulse measures 84 beats/minute. Client's bowel sounds are hypoactive in four quadrants. Client's incisional dressing shows a small amount of sanguineous drainage.

Client reports incisional pain as a level 3 on a pain scale of 1-10.

The nurse prepares to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes. Which action would be most important for the nurse to do? Check the diaper for recent urination. Give the infant a pacifier. Ensure that the room is kept warm. Tap lightly on the left inguinal ring.

Ensure that the room is kept warm.

A tornado strikes a community, resulting in multiple trauma victims. What is the most appropriate action of the nurse working in an acute care unit of the receiving facility in implementing the disaster preparedness plan? Contact and inform all registered nurses about the disaster to elicit their help in assisting with the casualties. Follow the formal written plan of action for coordinating the response of the hospital staff. Volunteer to report to whichever unit needs the most assistance. Transport medical supplies to where casualties are being evaluated.

Follow the formal written plan of action for coordinating the response of the hospital staff.

The nurse is caring for a client with peripheral vascular disease (PVD). Which action would the nurse do to ensure an accurate assessment? Keep the client warm. Maintain room temperature at 78°F (25.6°C). Keep the client uncovered. Match the room temperature to the client's body temperature.

Keep the client warm.

Why should an infant be quiet and seated in an upright position when the nurse assesses the fontanels? A mother will have less trouble holding a quiet, upright infant. The fontanels may recede, making assessment more difficult. The infant can breathe more easily when sitting up. Lying down and crying can cause the fontanels to bulge.

Lying down and crying can cause the fontanels to bulge.

A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb to the hips. What should the nurse do next? Select all that apply. Notify the family of the change. Notify the health care provider (HCP) of the change. Place respiratory resuscitation equipment in the client's room. Check for advancing levels of paresthesia. Have the client perform ankle pumps.

Notify the health care provider (HCP) of the change. Place respiratory resuscitation equipment in the client's room. Check for advancing levels of paresthesia.

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. Document history of the symptoms. Assess bowel sounds and abdominal tenderness. Insert an NG tube and connect to suction.

Obtain vital signs.

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. Percuss dullness in the lower left quadrant. Determine rebound tenderness below the symphysis. Inspect the urethral meatus for urine discharge.

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? Initiate hourly intake and output measurement. Request an order to insert a Foley catheter. Palpate for the bladder above the symphysis pubis. Force fluids to encourage voiding.

Palpate for the bladder above the symphysis pubis.

A graduate nurse is assessing a client with Meniere's Disease and a positive Romberg's sign. What is the nurse's highest priority when delivering care? Place client on fall precautions. Avoid antihistamine medications. Encourage a diet high in sodium. Teach methods of relaxation.

Place client on fall precautions.

The nurse is caring for a client who has just had an upper gastrointestinal (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. Tell the assistant to change thermometers and retake the temperature. Plan to give the client acetaminophen to lower the temperature. Ask the assistant to bathe the client with tepid water.

Promptly assess the client for potential perforation.

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. Because the adolescent is a minor, inform her parents about her medical history. Discussing the adolescent's medical history with her parents and thoroughly document it in the medical record. Before agreeing to maintain confidentiality, determine whether the adolescent is an emancipated minor.

Respect the adolescent's wishes and maintain her confidentiality.

A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that they desire to use the basal body temperature method for family planning. What instructions should the nurse give the client? Check the cervical mucus to see if it is thick and sparse. Take the client's temperature at the same time every morning before getting out of bed. Document ovulation when their temperature decreases at least 1°F (0.56°C). Avoid sex for 10 days after a slight rise in temperature.

Take the client's temperature at the same time every morning before getting out of bed.

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 will use the adaptive devices to assist with feeding. The client's vital signs will stabilize, returning to normal range. The client's skin will remain clean, dry, and intact. The client will return to optimal level of functioning.

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

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that the client has no active gag reflex. What is the next action by the nurse? Insert an oral airway. Withhold food and fluids. Position the client on the side. Introduce a nasogastric (NG) tube.

Withhold food and fluids.

Which client should the nurse assess first? a client being treated for chronic stable angina who reports a recent increase in chest pain frequency a client with type 2 diabetes requesting medication refills whose A1C level is 5 mg/dL a client being treated for right side heart failure who has 1+ pitting edema to lower extremities bilaterally and reports a 2 lb (0.9 kg) weight gain in the last week a client with chronic hypertension whose blood pressure today is 182/98 mm Hg

a client being treated for chronic stable angina who reports a recent increase in chest pain frequency

A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it is slightly concave. Additional assessment should proceed in which order? auscultation, percussion, and palpation palpation, percussion, and auscultation percussion, palpation, and auscultation palpation, auscultation, and percussion

auscultation, percussion, and palpation

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 diabetes insipidus with a urine specific gravity of 1.002 who is asking for morning coffee a client diagnosed with renal disease and a serum potassium level of 6.1 mEq/dL (6.1 mmol/L) who has limited output a client diagnosed with type 1 diabetes and a blood sugar level of 175 mg/dL (9.71 mmol/L) before breakfast a client with diagnosed hypoparathyroidism with a serum calcium level of 8.2 mEq/dL (2.05 mmol/L) who is having cramping in the legs

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

The nurse has received the change-of-shift report on the clients. Who should the nurse assess first? a client who had a temporary pacemaker inserted 2 hours ago, who is now pacing 1:1 with a heart rate of 70 a client with atrial fibrillation who is scheduled to go the cardiac catheterization lab at 10 am (1000) for an ablation a client with first-degree heart block and a heart rate of 62 who is dizzy when ambulating a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due

a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due

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 a client with peripheral vascular disease with a blood pressure of 190/102 mm Hg who is due to receive a scheduled beta blocker a client with a history of cerebral vascular attack, right sided weakness, blood pressure of 180/96 mm Hg who has a headache a client with type 1 diabetes with a fasting blood glucose of 102 mg/dL, blood pressure of 172/90 mm Hg and whose urine shows microalbuminuria

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 a client taking atenolol who has a heart rate of 58 a client with a nitroglycerine patch who has a headache a client taking captopril who has a nonproductive cough

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 with intractable vomiting and diarrhea a client who underwent cholecystectomy today a client with pain related to pancreatitis a client with colon cancer who is receiving chemotherapy a client with suspected tuberculosis (TB)

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

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area? on the bridge of the client's nose below the client's eyebrows below the client's cheekbones over the client's temporal area

below the client's cheekbones

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 sinusitis ringworm fifth disease

allergies

A client, age 75, is admitted to the hospital. Because of the client's age, how should the nurse modify the client's assessment? shortening it due to possible client fatigue speaking loudly and slowly addressing the client by first name allowing extra time for the assessment

allowing extra time for the assessment

The nurse is caring for a client experiencing acute abdominal pain. What is the first action by the nurse? administration of pain medication auscultation of all four quadrants using a stethoscope review of the abdominal X-ray report palpation for rebound tenderness over the lower abdominal area

auscultation of all four quadrants using a stethoscope

The nurse is assessing a client's nutritional status before surgery. Which observation would indicate poor nutrition in a 5-foot 7-inch (170-cm) female client who is 21 years of age? poor posture brittle nails dull expression weight of 128 lb (58.1 kg)

brittle nails

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? a bland diet tray milk, custard, and vanilla ice cream broth, gelatin cubes, and tea bananas, rice, applesauce, and toast

broth, gelatin cubes, and tea

A client is transferred to the acute stroke unit, and the nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care. The nurse is aware this information indicates what regarding a client's clinical status? alterations in speech and aphasic status quality and rate of pulses, respirations, and blood gas values changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person whether blood pressure is maintained within the lower end of desired parameters

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

While listening to a client's chest, the nurse notes a grating sound on inspiration and expiration. When communicating with the health care provider, what would the nurse request? nebulizer treatments chest X-ray arterial blood gas narcotic pain medications

chest X-ray

The nurse notes serous discharge when an abdominal dressing is changed. How would the nurse would document this drainage? white with sanguineous drainage clear, watery, yellow-tinged drainage tenacious and yellow drainage dark melena and foul smelling

clear, watery, yellow-tinged drainage

A client returns to the medical-surgical floor from the postanesthesia recovery room after a colon resection for adenocarcinoma. The client has comorbidities of stage 2 hypertension and a previous myocardial infarction. The first set of postoperative vital signs recorded are pulse rate of 110 bpm, respiration rate of 20/min, blood pressure of 130/86 mm Hg, and temperature of 98° F (36.7° C). The surgeon calls to ask if the client needs a unit of packed red blood cells. The nurse's response should be based on which data? Select all that apply. cyanotic mucous membrane warm, dry skin vital sign changes oxygen saturation

cyanotic mucous membrane vital sign changes oxygen saturation

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? breathing patterns, circulation patterns, and responses to hospitalization health habits, family relationships, affect, and thought patterns general survey results, eating habits, and ability to perform activities of daily living rest and sleep patterns, activity and exercise patterns, and coping and stress tolerance

health habits, family relationships, affect, and thought patterns

Which component of a client's medical record is the major source of subjective data about the client's health status? health history physical findings laboratory test results radiologic findings

health history

The nurse is inspecting the client's abdomen (see image above). The nurse should document that the client's abdomen: is flat and symmetrical. has an aortic pulsation. reveals a hernia. shows striae.

is flat and symmetrical.

After a local factory explodes, a nurse begins to triage the victims. Victim 1 is initially unconscious and not breathing. After the victim's airway is opened, 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? green yellow red black

red

During a routine otoscopic examination the nurse identifies these assessment changes. Which finding requires additional action? visualization of the ossicles through the tympanic membrane fine hairs in the auditory canal with dark brown wax light reflecting off the ear drum surface reddened tympanic membrane without discomfort

reddened tympanic membrane without discomfort

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

resonance

What are important nursing responsibilities when a referral to other health team members has been made for a client? ensuring that the physician reports the level of functioning of the client recommending that each health team member independently completes an assessment and then consult with each other recommending that each member read the history and nurse's notes to understand the client's progress sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living

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

When examining a client who has abdominal pain, a nurse should assess any quadrant first. the symptomatic quadrant first. the symptomatic quadrant last. the symptomatic quadrant either second or third.

the symptomatic quadrant last.

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? A (urethra opening midline of penis) B (urethra opening ends up in a position along the bottom of the penis) C (urethra opening is on the top of the penis)

C

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. rapid, deep breaths with abrupt pauses between each breath. rapid, deep breaths and irregular breathing without pauses. shallow breaths with an increased respiratory rate.

progressively deeper breaths followed by shallower breaths with apneic periods.

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 signs of abdominal distension, auscultation of reduced bowel sounds, and tympany upon percussion signs of kidney suppression with enlargement of the kidneys, reduced urine flow, and concentrated urine signs of metabolic alkalosis with disorientation because of loss of intestinal fluids

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

The nurse is monitoring a client during moderate sedation. The client is laying on the gurney with eyes closed and opens the eyes and moans when the nurse touches the shoulder, but not when the nurse says the client's name. The nurse charts the client responds to what type of stimuli? spontaneous verbal tactile painful

tactile

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 5 minutes every 10 minutes every 15 minutes every 20 minutes

every 15 minutes

A client is admitted to the preoperative clinic for a breast biopsy. Which information would the nurse enter into the medical record as objective data? Client reports that left breast is tender to touch. Client states, "I'm worried about the results." Client reports anxiety level at 7 out of 10. Blood pressure is 122/84 mmHg, and pulse is 100 beats/minute.

Blood pressure is 122/84 mmHg, and pulse is 100 beats/minute.

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

respiratory acidosis.

The nurse is assessing a client's activity tolerance. Which report from a treadmill test indicates an abnormal response? heart rate increased by 20 bpm immediately after the activity respiratory rate decreased by 5 breaths/minute diastolic blood pressure increased by 7 mm Hg pulse rate within 6 bpm of resting pulse after 3 minutes of rest

respiratory rate decreased by 5 breaths/minute

The nurse is monitoring a client who is receiving moderate sedation for a procedure. The client begins to display signs of restlessness and agitation. What assessment does the nurse perform first? oxygen saturation client's anxiety level pain scale level of consciousness

oxygen saturation

A community health nurse is planning to address the primary health needs of older adults living in their homes. What areas would the nurse assess first? exercise patterns, nutrition, mobility, and safety incidence of falls, resulting injuries, and rehabilitation needs disease identification and management medical visits and healthcare costs

exercise patterns, nutrition, mobility, and safety

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate? Educate the client about ways to maintain normal vision. Refer the client to a healthcare provider for possible corrective lenses. Encourage the client to purchase corrective lenses for reading. Tell the client that corrective lenses will be required for driving.

Refer the client to a healthcare provider for possible corrective lenses.

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include increased coronary artery blood flow. decreased posterior thoracic curve. decreased peripheral resistance. delayed gastric emptying.

delayed gastric emptying.

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? chlamydia herpes gonorrhea syphilis

herpes

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding? two to three bowel sounds per minute high pitched, tinkling bowel sounds high pitched gurgling noises in four abdominal quadrants sounds heard only in bilateral lower quadrants

high pitched gurgling noises in four abdominal quadrants

A nurse is assessing a client at the beginning of the shift. Which signs of hypoxia would alert the nurse to take further action? decreased pulse rate, increased blood pressure, and capillary refill time of 4 seconds increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis eupnea, oxygen saturation of 95%, and orthopnea pallor, hypotension, and bradypnea

increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis

To evaluate a client's cerebellar function, a nurse should ask "Do you have any problems with balance?" "Do you have any difficulty speaking?" "Do you have any trouble swallowing food or fluids?" "Have you noticed any changes in your muscle strength?"

"Do you have any problems with balance?"

A client has just been transferred to the postanesthesia recovery room following a laparotomy. The nurse has completed assessing vital signs. What other important initial assessments would the nurse make? skin color, warmth of extremities, and mental status metabolic rate, orientation, and presence of reflexes level of consciousness, pain level, and wound dressing emotional status, response to anesthesia, and social support systems

level of consciousness, pain level, and wound dressing

Using the Morse Fall Risk Scale, the nurse should initiate the highest fall risk precautions for which client? Older adult client with diabetes admitted with new-onset confusion who reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock Alert and oriented client with quadriplegia admitted for wound care of a stage IV pressure ulcer, receiving intravenous (IV) antibiotics per a peripherally inserted central catheter Client with a history of Parkinson disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during hospitalization has gotten out of bed without calling for assistance Client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain and no significant medical history, who smokes two packs of cigarettes per day, can be up independently, and has a stead

Client with a history of Parkinson disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during hospitalization has gotten out of bed without calling for assistance

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? alteration in level of consciousness altered cardiac functioning ineffective breathing pattern alteration in urinary elimination

ineffective breathing pattern

Which sign is an early indication that a client has developed hypocalcemia? tingling in the fingers depressed reflexes ventricular dysrhythmias memory changes

tingling in the fingers

The nurse is not able to palpate the left pedal pulses of a client with peripheral artery disease. What should the nurse do first? Auscultate the pulses with a stethoscope. Call the health care provider (HCP). Use a Doppler ultrasound device. Inspect the lower left extremity.

Use a Doppler ultrasound device.

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding? a passage of flatus pre- and post-feeding inability of the client to receive a rapid flow of the feeding intermittent epigastric tenderness formula in the client's mouth during the feeding, and increased cough

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

A client's arterial blood gas values are shown. The nurse should develop a care plan based on the fact the client is experiencing which clinical situation? pH: 7.24 PaCO2: 35 mmHg HCO3: 15 mEq/L metabolic acidosis metabolic alkalosis respiratory acidosis respiratory alkalosis

metabolic acidosis

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? administering digoxin to a client who has heart failure referring a client who reports joint pain to a healthcare provider specialist teaching a client who has asthma how to use a rescue inhaler obtaining a rubella titer on a woman who is planning to start a family

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

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention? a core body temperature of 97.9° F (36.6° C) confusion when listening to explanations of procedures polydipsia urine output of 90 mL over the past 6 hours

urine output of 90 mL over the past 6 hours

What is an expected assessment finding when caring for a client with a percutaneous feeding tube? Copious fluid leakage from the stoma Raised red papules around the stoma Moist bright red stoma with a scabbed area on one side Dark pink stoma without drainage

Dark pink stoma without drainage

Which is a priority nursing assessment of a reddened heel in a bed-ridden client? Test for blanching to the affected area. Rub the reddened area above and below the site. Check for perspiration and remove all linen to the extremity. Use powder to minimize shear forces to both heels.

Test for blanching to the affected area.

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 acetaminophen orally as needed small-volume nebulizer breathing treatments regular diet

intravenous fluid hydration

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) Face, Legs, Activity, Cry, Consolability (FLACC) scale Critical Care Pain Observation Tool (CPOT) MASCC Antiemesis Tool (MAT)

Richmond Agitation-Sedation Scale (RASS)