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: A

Rationale: The correct answer is A: Cost-saving measures. When utilizing evidence-based practice, the nurse should prioritize providing care based on research findings, considering client preferences, and leveraging their expertise. Cost-saving measures should not be the primary factor influencing care decisions as the focus should be on delivering the most effective and appropriate care based on evidence. Ignoring research findings, client preferences, or the nurse's expertise could compromise the quality of care provided. Thus, cost-saving measures are not a factor to consider when planning care with evidence-based practice.

Correct Answer: C

Rationale: The correct answer is C: Potassium level of 6.5 mEq/L. High potassium levels in ESRD patients can lead to life-threatening cardiac arrhythmias. Immediate action is needed to prevent complications. A: Weight gain may indicate fluid retention, but it's not an immediate concern. B: Blood pressure is elevated but not an urgent issue. D: Hemoglobin level of 10 g/dL is within the acceptable range for ESRD patients and does not require immediate action.

Correct Answer: B

Rationale: Excessive talking may indicate heightened anxiety as the client attempts to distract themselves from their worries.

Correct Answer: C

Rationale: The correct answer is C: Assessing for signs of bleeding. This is the priority assessment because heparin therapy increases the risk of bleeding. Signs of bleeding include bruising, petechiae, blood in urine or stool, and excessive bleeding from wounds. Monitoring blood pressure (A) is important but not the priority in this situation. Checking aPTT (B) is important for evaluating the effectiveness of heparin therapy but does not take precedence over assessing for bleeding. Measuring calf circumference (D) is used to detect changes in calf size due to DVT but is not the priority assessment while the client is on heparin therapy.

Correct Answer: B

Rationale: The client's size has nothing to do with an NPO status. Clients are at greatest risk for aspiration and vomiting during surgery when food and/or liquids are in the stomach. Preparation on the morning of surgery is time consuming, but it does not affect a client's NPO status. The gallbladder lies under the surface of the liver and is a part of the biliary tract, not the intestinal tract. Cholecystectomy does not involve the intestinal tract or its contents.

Correct Answer: B

Rationale: Pursed-lip breathing involves slow exhalation to prolong expiration and improve airflow.

Correct Answer: D

Rationale: The correct answer is D: Crackles in the lungs. Left-sided heart failure leads to fluid accumulation in the lungs, causing crackles on auscultation. This indicates pulmonary congestion. Peripheral edema (A) is more common in right-sided heart failure. Jugular vein distention (B) is typically seen in right-sided heart failure due to increased venous pressure. Hepatomegaly (C) is more common in conditions like liver disease, not specifically left-sided heart failure.

Correct Answer: D

Rationale: The correct answer is D. Sleep terrors are a classic example of parasomnias, which are abnormal behaviors during sleep. Cataplexy (A) is associated with narcolepsy, hypopnea (B) refers to shallow breathing, and sleep apnea (C) involves breathing interruptions.