During auscultation of the thorax, the nurse hears a low-pitched creaking sound. What should be the nurse's next action?
1. Have the patient cough to attempt to clear the sound.
2. Have the patient turn to the left side.
3. Collaborate with the physician regarding a chest X-ray.
4. Ask the patient to hold her breath.
4
Rationale 1: Crackles may clear with coughing, but this description does not match that of crackles.
Rationale 2: Positioning the patient will not change this assessment finding.
Rationale 3: An X-ray will likely be ordered, but this is not the first action indicated.
Rationale 4: This assessment represents a rub. The next assessment step is to differentiate pleural rub from cardiac rub by asking the patient to hold the breath. If the sound disappears, it is a cardiac rub.
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