A nurse begins a head-to-toe assessment of a client admitted with pneumonia. After introducing themselves and verifying the client’s identity, the client suddenly becomes increasingly short of breath and is unable to complete full sentences. What is the nurse’s priority action?

A postpartum client asks why the newborn receives only a small amount of colostrum after birth. Which nursing response is most accurate?

A nurse performs a cardiac assessment. Which nursing actions are appropriate? Select all that apply.

While palpating the cervical lymph nodes, the nurse notes a node that is hard, fixed, and nontender. Which nursing action is most appropriate?

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?