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A nurse is assessing a client who has sustained damage to cranial nerve VII. Which clinical observation will the nurse interpret as most consistent with this condition?

The RN is working in an ambulatory care clinical located in a large city. Which client would the nurse determine to be in most need of an emergency assessment?

The nurse is calling the healthcare provider using SBAR for a client who is short of breath. What would be included in the “A” section?

Which of the following nursing interventions does the nurse add to the care plan to help a patient with thick sputum mobilize and expectorate (cough up secretions) those secretions?

When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears it at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding?

How does pursed lip breathing affect respirations?

A 45-year-old patient reports severe abdominal pain rated at 8 out of 10 on the pain scale. The patient is restless, sweating, and has a facial grimace. You also note guarding of the abdomen upon palpation. Which of the following is the most important initial nursing action?

At last measurement, the client’s vital signs were as follows: oral temperature 98°F (36.7°C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2°F (38.5°C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurse’s first intervention at this time?

Which of the following is the most accurate oxygen saturation?

A nurse observes a student taking an adult patient’s tympanic temperature. What action by the student requires the nurse to intervene?