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    Hesi rn health assessment proctored exam

    Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

    Explanation & Rationale

    Condition: Pleural Effusion Pleural effusion is an accumulation of fluid in the pleural space, leading to difficulty breathing, decreased lung sounds, and dullness upon percussion (as noted in the nurse's assessment). Actions to Take: Auscultate the lungs for adventitious breath sounds: Pleural effusion may result in decreased or absent breath sounds due to fluid in the pleural cavity. Adventitious sounds such as crackles or a pleural friction rub can sometimes be heard, but in this case, decreased sounds are noted. Inspect the chest for lag on the affected side: In pleural effusion, there may be a delay in chest expansion on the affected side due to fluid buildup, which is consistent with the decreased expansion noted in the assessment. Parameters to Monitor: Cyanosis: Cyanosis may occur if the fluid accumulation severely impairs oxygenation. Respiratory rate and pulse: Monitoring respiratory rate and pulse is critical to assess for signs of respiratory distress and hypoxia, which could result from the pleural effusion.

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