While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

A 67-year-old male client is admitted to a health care facility with abdominal pain and suspected abdominal aneurysm. The client relates a 10-year history of high blood pressure and history of arterial insufficiency diagnosed 7 years ago. Following auscultation of the abdomen for bowel sounds, what other assessment should the nurse perform at this time?

The nurse is assessing the client's intake and output values for the shift (see chart below).

Intake for the shift

250mL Water

120mL Coffee

500mL Intravenous fluid

135 mL Orange Juice

120 mL Ice Cream

120 mL Jello

Output for the shift

545mL Urine

53mL Wound Drainage

200mL Emesis

375mL Urine

200mL Urine

75mL Loose Stool

480mL Urine

Based on these intake and output findings, what is the priority assessment by the nurse?

A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?

The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

A nurse is performing a lung assessment on an older adult client and notes the following: 

- Blood pressure: 136/90 

- Pulse: 88 beats per minute 

- Oxygen saturation: 92% 

- Respiratory rate: 18 breaths per minute 

- Lung sounds: Diminished breath sounds in all lung fields 

What would the nurse expect to be happening with the client?

The nurse is assessing a client in the acute care setting who has had a history of osteoarthritis. The client states that they have been taking ibuprofen four times a day for over five months and their pain continues to be poorly controlled despite all of their efforts. What is another assessment finding the nurse might anticipate for this client?

A nursing student correctly describes a risk diagnosis by which of the following statements?

A client in the emergency room is being admitted with severe right lower quadrant abdominal pain. The client states the pain is an 8 on the scale of 0-10 with sharp intermittent pain that has not been relieved by any intervention at this point. What will the nurse ask the client to do while palpating the abdomen?

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?