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 C
Explanation
When a labor and delivery nurse tells a coworker that a client of Asian descent probably did not want any pain medication because "Asian women typically are stoic," the nurse is expressing a belief known as a stereotype. A stereotype is an oversimplified and often inaccurate generalization about a group of people. The other options (Bias, Ethnic slur, and Stigma) are not directly related to this situation.
Correct Answer is A
Explanation
A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.
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