Nurse Performs Assessment Question & Answer Guide (With Explanation)

Understanding this question requires applying core subject principles.

What This Question Is About

This question relates to nurse performs assessment and requires a structured academic response.

How to Approach This Question

Break the problem into smaller parts and analyze each logically.

Key Explanation

This topic involves nurse performs assessment. A strong answer should include explanation, application, and examples.

Original Question

The nurse performs an assessment of the heart, lungs, and extremities. The nurse auscultates the heart sounds and notes an apical rate of 94 beats per minute. The rate is regular with no extra heart sounds detected. The PMI is located at the left midclavicular line at the 5th intercostal space. The jugular veins are full and distended while supine and in a sitting position. The lung sounds are clear in all lobes with vocal fremitus noted. Lower extremities are warm to touch with intact skin and +3 pitting edema of the ankles and feet noted bilaterally. Dorsal pedis and posterior tibial pulses are equal and 2+ amplitude. Which of the following should the nurse identify as unexpected findings and report to the provider? (Select all that apply.) Blood pressure Weight Location of PMI Vocal fremitus Pedal pulses Lower extremity appearance Jugular veins Apical pulse

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