A 45-year-old patient is admitted to the hospital following surgery. The nurse is assessing the patient’s physiologic response to pain. Which of the following is a common autonomic response to acute pain?

The nurse is assessing a patient admitted with a cerebral vascular accident (CVA). When assessing, a facial droop is noted. Before administering anything by mouth, what action should be performed?

The nurse is assessing a 79-year-old client’s posterior thorax while performing a focused respiratory assessment. The nurse should attribute what findings to age-related changes?

A murmur is noted on the auscultation of a new client. Which assessment placement below ensures a thorough assessment is performed. (Select All That Apply)

A nurse evaluates a student’s ability to perform a rebound tenderness test correctly. The nurse identifies the correct technique is being used when the student is observed palpating deeply and observing for?

A nurse is using the nursing process to care for a patient with an acute respiratory infection. Which of the following is the correct sequence of steps in the nursing process that the nurse should follow?

The nurse enters a patient’s room for an assessment and finds the patient with hemiparesis, a facial droop, and dysphasia. A code stroke is activated. What point of care intervention should be obtained while waiting for the rapid response team to rule out another possible diagnosis?

The client is requesting another dose of morphine for pain. Which value below would cause the nurse to question medication administration? 

The client’s metoprolol is due at 09:00. What vital sign below would warrant a nursing decision to hold the medication and not administer it? 

Upon assessment, a client has a Braden Assessment score of 12. What interventions are required for these patients? (Select All That Apply)