A nurse obtains a blood pressure reading of 158/92 mm Hg. The client reports that they just climbed two flights of stairs and immediately sat down for the measurement. What should the nurse do?

The nurse is assessing the respiratory rate of an adult client. Which finding should the nurse document as tachypnea?

During a health history, the nurse addresses a client using the name documented in the electronic health record. The client responds, “I actually go by Jordan, and I use they/them pronouns.” Which response by the nurse is most appropriate?

The nurse is assessing a client who reports abdominal discomfort. Which assessment should the nurse perform using auscultation?

The nurse obtains vital signs on an adult client. Which findings are not within expected range? Select all that apply.

Which action should the nurse take first when preparing the environment for a physical examination?

Which information should receive particular attention when documenting this client’s health history?

The nurse is preparing to assess a client’s chest. Which sequence of physical examination techniques is appropriate?

A nurse is interviewing a client with newly diagnosed hypertension and asks, “You haven’t been eating a lot of salty foods, have you?” Which revision would best improve the nurse’s question?

A nurse is documenting an interaction with a client who declines education about increasing physical activity. Which entry best reflects legally advisable documentation?