HESI Med Surg Level Three Study Guide | Latest 2023/24 | Updated & Verified | Guaranteed Success | 22 Pages

List four common symptoms of pneumonia the nurse might note on physical examination - - Tachypnea, shallow respirations with use of accessory muscles - abrupt onset of fever with shaking and chills (not reliable in older adults) - productive cough with pleuritic pain - rapid, bounding pulse State four nursing interventions for assisting the client to cough productively - - deep breathing q2 hours (may use incentive spirometer) - use humidity to loosen secretions (may be used with O2) - suctioning the airway if necessary, also helps with coughing - chest physiotherapy -increase fluids to 3L/day What symptoms of pneumonia might the nurse expect to see in an older client? - - confusion - lethargy/malaise - anorexia - rapid respiratory rate - tachycardia How does the nurse prevent hypoxia when suctioning? - oxygenate with 100% O2 for 1-2 minutes before and after suctioning During mechanical ventilation, what are three major nursing interventions? - - verify that the alarms are on - maintain settings, and check often to ensure that they are specifically set as prescribed by the HCP - verify functioning of ventilator at least q4 hours -keep airway clear by coughing and suctioningWhen examining a client with emphysema, what physical findings is the nurse most likely to see? - - bronchospasm and dyspnea - change in breathing pattern - over inflation of lungs... barrel chest - generalized cyanosis - either dry or productive cough - higher CO2 than average - low O2, usually between 90-92% - decreased breath sounds - coarse crackles in lungs that tend to disappear after coughing - orthopnea - poor nutrition, weight loss - activity intolerance -anxiety from not being able to breath What is the most common risk factor associated with lung cancer?