A nurse assesses a client after an open lung biopsy. Which ...

[Lisaclaire]

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.

Question 2

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?
 
  a. Tell the client that he needs to quit smoking to stop further cancer development.
  b. Encourage the client to be completely honest about both tobacco and marijuana use.
  c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
  d. Avoid giving the client false hope regarding cancer treatment and prognosis.

[Mholman93]

Answer to Question 1

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.

Answer to Question 2

ANS: C
Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure. Ask the client whether any of these substances are used now or were used in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs per day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Quitting smoking may not stop further cancer development. This statement would be giving the client false hope, which should be avoided, but is not as important as maintaining a nonjudgmental attitude.

[Lisaclaire]

Correct answers!

[Mholman93]

Great! Please up vote