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A nurse auscultates intermittent soft clicks and gurgles bowel sounds at a rate of 5-30 per minute in all four quadrants. How should the nurse interpret this finding?

The nurse is performing light palpation of the client’s abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment?

A 79-year-old Hispanic male with type 2 diabetes and hypertension is undergoing a routine lower-extremity vascular assessment.The nurse is unable to palpate the dorsalis pedis pulse on either foot after warming the client’s skin. Capillary refill is less than 2 seconds, and the posterior tibial pulses are palpable bilaterally. Which nursing action is most appropriate next?

The presence of faint pedal pulses in a client has prompted the nurse to perform a position change test for arterial insufficiency. What finding would suggest that the client may have arterial insufficiency?

The nurse is preparing to auscultate a client’s thorax during a respiratory assessment. Which action should the nurse prioritize?

While inspecting the lower extremities of a client, the nurse observes an ulcer. What would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply.

A nurse assesses a patient’s palate and notes a thick white plaque that does not scrape off. The most appropriate response is:

A nurse teaches a client non-medication strategies to reduce gastroesophageal reflux disease (GERD) symptoms. Which of the following demonstrates the client’s understanding of the teaching and actions that should be taken by the client? (Select all that apply.)

The nurse is assessing a client’s first heart sound. The nurse interprets this finding as indicating which heart action?

During a routine lung assessment, the nurse hears adventitious sounds while auscultating a client’s lungs. Which action should the nurse take first?