A nurse completes a head-to-toe assessment and identifies diminished breath sounds, oxygen saturation of 89%, and productive cough. Which nursing action best represents the implementation phase?

A nurse asks the client to protrude the tongue and move it from side to side. Which cranial nerve is the nurse assessing?

A nurse is assessing a client with suspected ascites. Which assessment technique would provide the most useful information regarding the presence of excessive abdominal fluid?

A nurse is assessing a client with suspected mitral valve regurgitation. To best evaluate the murmur, where should the nurse place the stethoscope?

A nurse assesses primitive reflexes in a healthy newborn. Which findings are considered expected? Select all that apply.

A nurse is assessing pain in an adult client who is mechanically ventilated, sedated, and unable to communicate verbally. Which assessment tool is most appropriate?

A nurse is assessing a client who reports dizziness. Which question is a leading type of question?

A nurse assesses a pregnant client and notes dark patches across the forehead and cheeks. Which finding should the nurse document?

Match each assessment action with the appropriate structure or assessment site. Each option may be used once, more than once.

A postoperative client has the following assessment findings: Temperature: 37.2°C (99°F) Heart rate: 118/min Respiratory rate: 26/min Blood pressure: 88/54 mm Hg Oxygen saturation: 95% on 2 L/min nasal cannula Which finding requires the nurse’s priority intervention?