A nurse is conducting a lung assessment on a client suspected of having pneumonia. Which finding should the nurse report to the physician immediately?
Asymmetrical chest expansion
Breath sounds equal bilaterally
Bilateral symmetric vocal fremitus
Chest symmetrical
The Correct Answer is A
During a lung assessment on a client suspected of having pneumonia, the nurse should report asymmetrical chest expansion to the physician immediately. Asymmetrical chest expansion can be a sign of a serious lung condition such as pneumonia. The other options (Breath sounds equal bilaterally, Bilateral symmetric vocal fremitus, and Chest symmetrical) are normal findings and do not need to be reported immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should implement the measure of encouraging the client's daughter to prepare food at home and bring it to the client. This can help improve the client's nutritional intake by providing familiar and appetizing meals that may be more appealing to the client than hospital food. It is important for the nurse to work with the client and their family to identify strategies that can help improve the client's nutritional intake during their hospitalization.
Correct Answer is D
Explanation
When collecting equipment to administer a unit of packed red blood cells, the nurse should use 250 mL of normal saline to initiate the IV for this transfusion ³. Normal saline is the only compatible solution to use with blood or blood components ³. The other options (100 mL of 5% dextrose and 1/2 normal saline, 1,000 mL of lactated Ringer's solution, and 500 mL of 5% dextrose and water) are not appropriate IV fluids to use when administering a unit of packed red blood cells.
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