After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?

Correct Answer: C

Rationale: The correct answer is C because reduced breath sounds after an open lung biopsy could indicate a potential complication like pneumothorax. In this situation, it is crucial for the nurse to call the physician immediately for further assessment and intervention. This prompt action can help prevent worsening of the client's condition and ensure timely treatment. Choice A is incorrect because applying oxygen and pulse oximetry is not directly addressing the potential complication of reduced breath sounds. Choice B is incorrect because withholding pain medication based solely on a low heart rate is not appropriate without further assessment. Choice D is incorrect because decreasing oxygen flow rate without proper assessment could be harmful if the client is experiencing respiratory distress.

Correct Answer: B

Rationale: The correct answer is B: Assess the client's level of consciousness. This is the priority because changes in consciousness can indicate deteriorating respiratory status or potential respiratory distress. Next steps would depend on the assessment findings. A: Encouraging fluid intake is important but not the first priority. C: Raising the head of the bed helps with breathing but doesn't address potential immediate respiratory distress. D: Providing humidified oxygen may be necessary but assessing consciousness comes first to determine the urgency of oxygen therapy.

Correct Answer: C

Rationale: Step 1: Wheezes indicate narrowing of the airways, typically seen in conditions like asthma. Step 2: Inhaled bronchodilators help dilate the airways, relieving wheezing and improving breathing. Step 3: Hence, administering an inhaled bronchodilator is the correct intervention for wheezes. Summary: A: Increasing oxygen flow does not directly address the issue of wheezes. B: Encouraging coughing does not address the narrowing of airways seen with wheezes. D: Deep breathing does not specifically target the narrowing of airways associated with wheezes.

Correct Answer: B

Rationale: The correct answer is B: Do you have any chronic breathing problems? This question is relevant because equal AP and lateral chest diameters can indicate a barrel chest, which is often associated with chronic breathing problems like chronic obstructive pulmonary disease (COPD). Chronic breathing problems can lead to this specific chest shape due to increased lung volume. Choice A is incorrect as it does not directly relate to the physical assessment findings. Choice C is incorrect as it focuses on exercise habits rather than the client's current health status. Choice D is incorrect as it does not address the potential underlying health issue indicated by the chest measurements.

Correct Answer: B

Rationale: The correct answer is B: Absent breath sounds. This finding requires immediate action because it could indicate a pneumothorax, which is a potentially life-threatening complication following a lung biopsy. Absent breath sounds suggest air trapped in the pleural space, leading to lung collapse. Immediate intervention is necessary to prevent respiratory distress. A: Increased temperature is concerning but may indicate infection, which would require monitoring and possibly treatment, but it is not as urgent as addressing a potential pneumothorax. C: Productive cough is common post-lung biopsy and may be managed symptomatically. It does not typically require immediate action. D: Incisional discomfort is expected after a biopsy and can be managed with pain medication. It does not indicate a critical issue requiring immediate intervention.