The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should the nurse report to the physician immediately?
1. Chest symmetrical
2. Breath sounds equal bilaterally
3. Asymmetrical chest expansion
4. Bilateral symmetric vocal fremitus
Correct Answer: 3
Rationale 1: Symmetrical chest expansion is an expected finding.
Rationale 2: Bilaterally equal breath sounds is a normal assessment finding.
Rationale 3: Chest expansion should be symmetrical.
Rationale 4: Bilaterally equal vocal fremitus is a normal assessment finding.
You might also like to view...
The nurse is working with a client to create a crisis care card in the event the client wants to attempt suicide in the future. Which of the following should be included on this card?
1. Name of client 2. Address of client 3. Name of client's physician 4. Name and address of friend to call in case of a crisis
The nurse is using the Pain Assessment in Advanced Dementia Scale (PAINAD) to assess an older adult patient with dementia. Which finding would score a 1 for this patient?
1) Loud moaning and groaning 2) Facial grimacing 3) Occasional labored breathing 4) Rigid, clenched fists
The nurse learns that the client has been started on sotalol (Betapace). What is the most likely rationale for this?
1. Hypertension 2. Serious ventricular dysrhythmia 3. Atrial dysrhythmia 4. Chronic atrial fibrillation
When assessing a community, what particular component is essential to determine first?
A. Areas of strength B. Areas of need C. Balance of inputs to outputs D. Openness to intervention