After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?

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: 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.

Correct Answer: D

Rationale: The correct answer is D because ensuring informed consent is crucial before any invasive procedure to protect the client's autonomy and rights. This involves confirming the client's understanding of the procedure, risks, benefits, and alternatives. Option B is correct as it directly relates to the ethical and legal aspect of the procedure. Option A is incorrect as it focuses solely on monitoring oxygen saturation, which is important but not the priority before thoracentesis. Option C is incorrect as simply explaining the procedure does not ensure the client's understanding or consent.

Correct Answer: D

Rationale: The correct answer is D: Place the client in a high Fowler's position. Placing the client in a high Fowler's position helps improve lung expansion and oxygenation by maximizing chest expansion. This position facilitates better breathing mechanics and can alleviate respiratory distress. Choice A is incorrect because administering oxygen via nasal cannula should be done after positioning the client properly. Choice B is important but assessing vital signs alone may not provide immediate relief to the client's breathing difficulty. Choice C, notifying the Rapid Response Team, is not the best immediate action as positioning the client correctly should be the priority before seeking additional help.

Correct Answer: D

Rationale: The correct answer is D, assessing the client's mental status and level of consciousness. This is the first action to take because a respiratory rate of 10 breaths/min in a COPD client receiving oxygen therapy may indicate respiratory depression or impending respiratory failure. Assessing mental status and level of consciousness can help determine if the client is experiencing hypoxia. Increasing oxygen flow rate (A) without assessing the client first can be dangerous if the client is retaining carbon dioxide. Administering a bronchodilator (B) may not address the underlying issue of respiratory depression. Encouraging deep breaths (C) may not be appropriate if the client is in respiratory distress.