A nurse is caring for a 36-year-old male client on a medical-surgical unit. Based on the client’s current status, which should the nurse include in a focused assessment?

Observe the client’s respirations for rate, rhythm, and depth

Inspect the skin and mucus membranes

Measure the apical pulse for 60 seconds

Auscultate chest

Have the client demonstrate use of the incentive spirometer

Determine the heart rhythm