A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?
a. Client states he is dizzy. - Nurse applies oxygen and pulse oximetry.
b. Client's heart rate is 55 beats/min. - Nurse withholds pain medication.
c. Client has reduced breath sounds. - Nurse calls physician immediately.
d. Client's respiratory rate is 18 breaths/min. - Nurse decreases oxygen flow rate.
ANS: C
A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately. Dizziness after the procedure is not an expected finding. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.
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