{heart (ventricular gallop) sound indicates a cardiac concern and requires furthe

{Rationale: The finding should be documented as an abrasion. A wound is a break i

result of dilation and congestion of superficial capillaries; erythema is seen in

r again assesses the accommodation response. The patient\’92

{A nurse who is performing a physical assessment is preparing to auscultate breat

audible expulsion of air from the lungs. What should the nurse document that the

{NCLEX: Health Promotion and Maintenance: Basic Care and Comfort}\plain \f0

{A nurse is monitoring a 58-year-old patient who is receiving diuretic therapy. W

{The nurse should keep a hand hovering over the infant during the weighing to pre

{This is incorrect. A deteriorating Glasgow Coma Scale indicates neurological com