The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse should determine if the client has:
1. Decreased chest movement on the affected side.
2. Normal bronchial breath sounds.
3. Hyperresonance on percussion.
A pleural effusion is a collection of fluid between the pleural layers of the lung. The effusion decreases chest wall movement on the affected side. The nurse should expect the breath sounds to be decreased or diminished over the affected area. Because of the presence of fluid, percussion would elicit dullness, not hyperresonance. Fever may be present if empyema (purulent pleural fluid with bacterial infection) has developed, but not in the case of a nonpurulent pleural effusion.
CN: Basic care and comfort; CL: Analyze
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