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?

A 4-year-old child is postoperative and crying intermittently. The child is able to speak in short sentences but becomes tearful when asked about pain. The nurse needs the most accurate pain assessment tool. Which tool is most appropriate?

While assessing a postoperative client, the nurse notes the incision is red with moderate serous drainage. The client states, “It feels warm and throbbing.” Which entry best demonstrates accurate data collection without interpretation?

A 45-year-old client presents with an acute onset of right-sided facial weakness following a recent upper respiratory infection. The client reports difficulty keeping liquids in the mouth, inability to fully close the right eye, decreased tearing, and facial asymmetry when attempting to smile. The nurse suspects dysfunction of Cranial Nerve VII. Which assessment finding best supports impairment of Cranial Nerve VII motor function?

A hospitalized client diagnosed with heart failure develops increased bilateral lower extremity edema. The nurse evaluates weight changes, lung sounds, oxygen saturation, and fluid intake/output. Which description best classifies this assessment?