The nurse is performing a respiratory assessment on a client. Which of the following findings should the nurse report to the practitioner?
A.
Clear and equal breath sounds bilaterally
B.
Oxygen saturation of 98% on room air
C.
Cough producing clear, thin sputum
D.
Visible use of accessory muscles during inhalation
The correct answer is:
D. Visible use of accessory muscles during inhalation
Explanation: The use of accessory muscles during inhalation is an abnormal finding and indicates that the client may be experiencing respiratory distress or difficulty in breathing. This could be a sign of conditions such as severe asthma, chronic obstructive pulmonary disease (COPD), or other respiratory issues that need further evaluation and intervention by the practitioner.
- A. Clear and equal breath sounds bilaterally are normal and do not require reporting.
- B. Oxygen saturation of 98% on room air is within the normal range and does not need reporting.
- C. Cough producing clear, thin sputum can be normal, especially if it is not associated with other symptoms.