HESI Med-Surg Respiratory.

HESI Med-Surg (Respiratory) List four common symptoms of pneumonia that the nurse might note on a physical examination. Fever and chills, diminished breath sounds, productive cough and tachypnea State 4 nursing interventions for assisting the client to cough productively Encourage deep breathing, staying hydrated, humidify to loosen secretions, and suction airway to stimulate coughing. What symptoms of pneumonia might the nurse expect to see in an older client? Confusion, lethargy, rapid RR and anorexia how does the nurse prevent hypoxia while suctioning? Hyperoxygenate with 100% O2 before and after During mechanical ventilation, what are three major nursing interventions? Monitoring respiratory status, establish communication, and keep airway clear When examining a client with emphysema, what physical findings do you expect? Dry productive cough, clubbed nails, crackles, decreased lung sounds and a barreled chest Most common risk of lung cancer Smoking Describe the preoperative nursing care for a client getting a laryngectomy Teach client and family how to use the equipment, plan a communication method, refer to a speech pathologist and rehab program. List 5 interventions after a chest tube insertion Maintain a dry occlusive dressing, keep tubing tight and taped, monitor clinical status, encourage deep breathing, monitor drainage and mark fluid level. What do you do when a chest tube disconnects from water suction? place tube in a sterile water container to reactivate seal and tell the HCP. What do you do when a chest tube comes out of the patient? Apply occlusive dressing, taped on only 3 sides, and tell the HCP STAT. What instructions should be given to a client after radiation therapy? Do not wash off lines, wear soft cotton, avoid powders and creams on the radiation site. What are the precautions for TB? Private negative pressure room, mask for anyone entering, mask for client when they leave. 4 components of teaching for a patient with TB: cough into tissues and dispose into special bags, long term need for daily medication (6-9months), good hand-washing technique, report symptoms of deterioration or blood in secretions