During abdominal percussion of a client with mild constipation, the nurse notes: Predominanttympany in the RLQ Localizeddullness in the LLQ The client denies pain, fever, or acute symptoms. Which interpretation is most accurate?

Case Scenario:  A nurse is caring for Mr. Reynolds, a 72-year-old client admitted with pneumonia and dehydration. During the assessment, the student obtains: Temperature: 38.1°C (100.6°F) Heart rate: 112 beats/min Respiratory rate: 24 breaths/min Blood pressure: 92/58 mm Hg Oxygen saturation: 91% on room air The client is awake, alert, and oriented ×4; skin is warm and slightly dry; and reports, “I feel weak and a little short of breath when I move.” The provider has prescribed oxygen PRN for SpO₂ < 92% and IV fluids at 75 mL/hr. Which finding should the nursing student identify as the highest priority?

A client presents for prenatal care. She reports the following history: One full-term vaginal delivery at 39 weeks (child alive) One preterm delivery at 34 weeks (child alive) One spontaneous miscarriage at 10 weeks Currently pregnant What is the correct GTPAL documentation?

The nurse is caring for a 65-year-old client hospitalized with acute heart failure. The nursing care plan includes a goal that “the client’s oxygen saturation will remain above 94% on room air within 48 hours.” After 48 hours, the nurse assesses the client and finds the oxygen saturation is 92% on room air, but the client reports feeling “much less short of breath” and has clear lung sounds upon auscultation. How should the nurse document the status of the goal and determine the next logical step in the nursing process?

A nurse is assessing the radial pulse of an adult client during a routine cardiovascular examination. The nurse aims to obtain an accurate evaluation of pulse characteristics while avoiding common assessment errors that may alter findings. Proper technique is essential to ensure reliable measurement of perfusion and cardiac rhythm. Which action by the nurse demonstrates correct radial pulse assessment technique?

The nurse auscultates a low-pitched extra sound immediately after S2 in a 68-year-old client with dyspnea and peripheral edema. What is the most accurate interpretation?

During auscultation of the right carotid artery, the nurse hears a blowing, swishing sound. How should this finding be interpreted?

A client reports severe right upper quadrant pain. How should palpation be performed?

A nurse is completing documentation after assessing an older adult client who reports difficulty sleeping and daytime fatigue for the past week. Assessment findings include BP 138/84 mmHg, HR 92 bpm, RR 18/min, Temp 98.4°F, mild periorbital darkening, frequent yawning, and slowed responses during conversation. The client states, “I wake up several times during the night and feel exhausted during the day.”  Which documentation entry best demonstrates accurate separation of subjective and objective data without interpretation or diagnostic labeling?

A 2-year-old toddler is brought to the emergency department for lethargy and decreased activity. During assessment, the nurse observes the child wearing heavily soiled clothing with a strong odor, untreated severe dental caries, poor hygiene, and weight significantly below the expected percentile for age. The child demonstrates minimal eye contact, flat affect, and limited verbalization. No acute injury is noted. The caregiver states, “She’s just a picky eater and hates brushing her teeth,” and appears unconcerned. The nurse reviews the chart and notes multiple missed well-child visits and incomplete immunizations. Based on these findings, which action should the nurse take first?