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 D
Explanation
It would be inappropriate to delegate the unsupervised task of transferring a client from bed to chair to an unlicensed assistant (UAP) if it was the client's first time out of bed after surgery. In this situation, the client may have specific needs or limitations that require the expertise and assessment of a licensed healthcare provider. The nurse should supervise the transfer to ensure that it is performed safely and appropriately for the client's condition.
Correct Answer is B
Explanation
When educating a preoperative client on how to effectively deep breathe, the nurse should instruct the client to make each breath deep enough to move the bottom ribs. This helps to ensure that the client is taking deep breaths and fully expanding their lungs. The other options (Breathe in through the mouth and out through the nose, Practice deep breathing at least once each week, and Breathe through the mouth when you inhale and exhale) are not accurate instructions for effective deep breathing.
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