The nurse is assessing a client with a severe left pleural effusion. Which of the following findings are expected? Standard Text: Select all that apply
1. Absent breath sounds on the left side
2. Tracheal shift to the right
3. Hyperresonance upon percussion.
4. Bronchial breath sounds of the right side
5. Pleural friction rub auscultated.
1,2,5
Rationale 1: Absent breath sounds on the left side. In this condition, fluid accumulates in the pleural space and may result in absent breath sounds on the affected side.
Rationale 2: Tracheal shift to the right. In this condition, fluid accumulates in the pleural space. The trachea may shift to the unaffected side.
Rationale 3: Hyperresonance upon percussion. The trapping of air in the alveoli will produce a sound of hyperresonance upon percussion. This is not a typical finding in someone who has been diagnosed with a pleural effusion.
Rationale 4: Bronchial breath sounds of the right side. This is not a typical finding in someone who has been diagnosed with a pleural effusion.
Rationale 5: Pleural friction rub auscultated. In this condition, fluid accumulates in the pleural space, and a pleural friction rub may be present during auscultation.
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