A client is admitted to the hospital with suspected meningitis.

Which assessment finding should alert the nurse to perform a Kernig's sign test?

Cyanosis of the lips and nail beds

Rationale: Cyanosis of the lips and nail beds indicates severe hypoxia and requires immediate intervention. The nurse should report this finding to the provider and administer oxygen as prescribed.

Incorrect options:

A) Barrel-shaped chest - This is a common finding in clients with COPD, due to the increased anteroposterior diameter of the chest caused by air trapping and hyperinflation of the lungs. It does not require immediate intervention.

B) Clubbing of the fingers - This is a sign of chronic hypoxia and is often seen in clients with COPD. It results from the proliferation of connective tissue at the base of the nails due to chronic low oxygen levels. It does not require immediate intervention.

D) Wheezes on auscultation - This is an expected finding in clients with COPD, due to the narrowing of the airways caused by inflammation, mucus production, and bronchospasm. It does not require immediate intervention.

Document the error in the client's medical record and the incident report.

Rationale: The nurse should document the error in both the client's medical record and the incident report, as this is part of the legal and ethical responsibility of the nurse. The documentation should include the facts of what happened, what actions were taken, and the client's response.

Incorrect options:

B) Notify the client's physician and the risk management department. - This is not the most appropriate action, as the nurse should first report the error to the nurse manager, who will then decide who else needs to be notified and how to proceed with further investigation and follow-up.

C) Explain the error to the client and apologize sincerely. - This is not the most appropriate action, as the nurse should first ensure that the client is safe and stable, and then consult with the nurse manager and the legal department before disclosing the error to the client. The nurse should also avoid admitting fault or liability, as this could have legal implications.

D) Wait until the end of the shift to report the error. - This is not an appropriate action, as the nurse should report the error as soon as possible, preferably within an hour of its occurrence. Delaying reporting could compromise client safety and quality of care, as well as increase the risk of legal action.