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Assessment of the Respiratory System

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Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.


Client has reduced breath sounds- Nurse calls physician immediately.
Occupation and hobbies.
Assessing the level of consciousness.
Wheezes are heard in central areas- The nurse administers an inhaled
bronchodilator.
6. Do you have any chronic breathing problems?
7. Absent breath sounds
8. Validate that informed consent has been given by the client.
9. The trachea is deviated toward the opposite side of the neck.
10.Assess the clients gag reflex before giving any food or water.
11.Assistance with activities of daily living.
12.Smoking while taking this medication will increase your risk for stroke.
13.Notify the Rapid Response Team.
14.Document the findings.
1. Visual hallucinations, Impaired judgement
2. Encourage deep breathing and coughing, Ambulate the client three times
each day, Provide a diet high in protein and vitamins.
3. What response do you have when you eat avocados, I will document this
in your record so all of your providers will know, Have you ever been
treated for this allergic reaction.
4. I held the clients morning bronchodilator medication, I advised the client
not to smoke for 6hours prior to the test The client is alert and can follow
your commands.\
5. Find an activity that you enjoy and will keep your hands busy, Drink at
least 8 glasses of water each day, make a list of reasons why you want to
stop smoking.
Care of patients requiring oxygen therapy or tracheostomy
1. 21%
Room air is 21% oxygen.
2. Ensure informed consent is on the chart
3. Assess the clients oxygen saturation.
4. Measure and compare cuff pressure
5. Assess the clients lung sounds.
6. Tying a square knot at the back of the neck
7. Applying suction while inserting the catheter
8. Intact skin behind the ear.
9. Stay with the client and have someone else call the provider immediately.
10.The client has joined a book club that meets at the library.
11.Apply water-soluble ointment to nares and lips.
12.Determine if the client can switch to a nasal cannula during the meal.
13.Immediately increase the flow rate.
1. The client does not allow smoking in the house, Electrical cords are in good
working order, and Flammable liquids are stored in the garage.
2. Applying water-soluble lip balm to the clients lips, reminding the client cough
and deep breath often.

3. Create a communication system, Try loose-fitting shirts with collars, Wear


fashionable scarves.
4. Cognition, Dexterity, Range of motion, Vision.
5. Absorptive atelectasis, Combustion, Dried Mucous membranes, Toxicity.
Care of Patients with Noninfectious Upper Respiratory Problems
1. Airway Patency
2. Collect the nasal drainage on a piece of filter paper.
3. Ask the client if he or she has ever been evaluated for sleep apnea.
4. Tuck your chin down when swallowing.
5. A 55-year old woman who is 50 pounds overweight.
6. When I speak, I will whisper rather than use a normal tone of voice.
7. Initiate standard precautions.
8. Ask the client to gargle with mouthwash containing lidocaine.
9. This is normal after surgery, what type of food does you like to eat?
10.Assess airway patency, breathing and circulation.
11.Contact the provider and prepare for intubation.
12.This medication will promote daytime wakefulness. (Modafinil)
13.Make sure the string is taped to the clients cheek.
14.Make sure you can clean the humidifier to prevent infection.
1. Observe for clear drainage, Assess for signs of bleeding, Watch the client for
frequent swallowing, Ask the client to open his or her mouth.
2. Hypertension, Leukemia, Cocaine use.
3. Stridor, Ecchymosis behind the ear.
4. 43 year old diagnosed with cancer after a lung biopsy 2 days ago, An 88 year
old with esophageal cancer who is awaiting gastric tube placement.
5. You will need to cut the wires if you start vomiting, Eat six soft or liquid
meals each day while recovering, Irrigate your mouth every 2 hours to
prevent infection, sleep in a semi-fowlers position after surgery.
6. A 24 year old with a traumatic brain injury, A 58 year old at risk for aspiration
following radiation therapy, A 66 year old who is quadriplegic and a sacral
ulcer. And 80 year old who is aphasic after a cerebral vascular accident.
Care of patients with non-infection Lower Respiratory Problems
1. A 27 year old client with heart rate of 120 beats/min.
2. Ask about medications the client is currently taking.
3. I will take this medication every morning to help prevent an acute attack.
4. The client places his or her hands on his or her abdomen.
5. Omelet, soft whole wheat bread.
6. It is unlikely you will become addicted when taking medicine for pain.
7. (Salmeterol) I will use the drug when I have an asthma attack.
8. Share any thoughts and feelings that cause you to limit social activities.
9. Eat a well-balanced, nutritious diet
10.Cover the insertion site with sterile gauze.
11.Encourage oral rinsing after fluticasone administration.
12.Keep the client isolated from other clients with cystic fibrosis.
13.Administer pain medication and encourage the client to take deep breathing.
14.When the tube becomes disconnected from the drainage system.

15.Increased pulmonary pressure creating a higher workload on the right side


of the heart.
16.Do you experience shortness of breath with basic activites.
17.It is important to use this type of inhaler every day. Lets identify potential
community services to help you
18.A 52 year old in a tripod position using accessory muscle to breath.
19.I plan to use cotton balls to cushion the oxygen tubing on my ears.
20.Keep padded clamps at the bedside for use if the drainage system is
interrupted.
21.Your risk for chronic obstructive pulmonary disease is higher, especially if
you smoke.
22.Since you have a family history of cystic fibrosis, I would encourage you
and your partner to be tested.
23.Cholinergic antagonist- Causes bronchodilation by inhibiting the
parasympathetic nervous system.
24.Inflammation of the pleura.
25.Assess for airway obstruction.
26.Make sure the device reads zero or is at base level, 4,2,1,3,5,6,7.
27.Insert the mouth of the inhaler into the nonmouth oiece end of the spacer.
28.Initiate oxygenation therapy to increase saturation to 92%.
1. Administer oxygen to keep saturations greater than 94%, Administer
prescribed albuterol (Proventil) inhaler.
2. Tracheal deviation, sudden onset of SOB, Drainage greater than 70 ml/hr,
and disconnection at Y site.
3. Avoid drinking fluids just before and during meals, Rest before meals if
you have dyspnea, Have about six small meals a day.
4. Do you have any difficulty sleeping? How long does it take to perform
your morning routine? Have you lost any weight lately?
5. Tracheal deviation and Sudden onset of shortness of breath.
6. Ask the client to drink 2 liters of fluids daily. Add humidity to the prescribed
oxygen. Use a vibrating positive expiratory pressure device.
7. Keep an intravenous line dedicated strictly to the infusion. Ensure that there
is always a backup drug cassette available. Use strict aseptic technique
when using the drug delivery system.
Care of Patient with vascular problems
1. Assessing blood pressure in both upper extremeties.
2. Triglycerides 198 mg/dL
3. Baked chicken breast, broccoli, tomatoes.
4. Ask if the client eats grapefruit.
5. Most people with hypertension do not have symptoms.
6. It is hypertension with no specific cause
7. African American churches
8. Assist in finding one change the client can control.
9. Furosimide(Lasix) potassium 2.1
10.Could you walk further than that a few months ago
11.My hands shake when I try to do things requiring coordination
12.no, it may interfere with the warfaring
13.No, women should only have one beer a day as a general rule

14.Client who had a first dose of captopril (Capoten) and needs to use the
bathroom.
15.Distal pulse on affected extremety 2+/4+
16.Assess distal pulse and skin color.
17.Appropriate had hygiene before giving care.
18.Notify the Rapid Response Team
19.PALPATE THE ABDOMEN IN ALL 4 QUADRANTS
20.Oxygen saturation of 98%
21.Apply a warm moist pack.
22.Measure for new compression stockings
23.Participate in blood pressure screening at the mall.
24.Assess the reason behind the clients fear.
25.Assess the clients lung sounds and oxygenation.
26.Consult with the Wound Care Nurse.
27.I can use a heating pad on my legs if its set on low
28.Ensure the client has a patent airway.
29.Assess the clients ankle-brachial index.
1. Applying elastic compression stockings Elevating the legs when sitting or
lying Reminding the client to do leg exercises
2. Raising the siderails on the bed and Recording baseline vital signs
3. Apply compression stockings assist with ambulation. Offer fluids frequently.
4. Assess the client for bleeding Monitor the daily (aPTT) and weight the client
daily
5. Dietary restriction follow up laboratory monitoring possible drug drug
interaction reason to take medication.
6. I will keep my feet dry Lotion is important Washing my feet
7. Ask client to describe current emotions, assess the client support, offer to
stay with the client
8. Atherosclerosis, history of htn, history of smoking
9. Assess distal pulses every 10 minutes, Notify rapid response team and take
vital signs every 10min.
Care of Patients with Urinary Problems
1. A 58 year old femalewho is not taking estrogen replacement
2. Notify the provider and start an intravenous line for parenteral antibiotics.
3. Low estrogen levels can make the tissue more susceptible to infection.
4. An orange color in my urine should alarm me
5. I will limit my total intake of fluids
6. A 78 year old female who is confused
7. Changing the clients incontinence brief when wet
8. Use the Valsalva maneuver.
9. Can we discontinued the indwelling catheter
10.I should drink at least 3 liters of fluid every day.
11.Allopuriinol (Zyloprim)
12.Apply an ice pack to the site
13.Obtain urine sample for culture and sensitity
14.An 86 year old male with 50 pack year cigarette smoking history
15.The ileostomy stoma is pale and cyanotic in appearance

16.Do you smoke cigarettes


17.Wouldyou like to speak with someone who has an ileal condition
18.Use a second form of birth control..
19.Buy slacks with elastic waistbands that are easy pull down
20.What medications are you taking
21.Try to consciously jold your urine..
22.A 58 year old postmenopausal client who is not taking estrogen therapyelectrical stimulation.
23.Do any of your family members have this problem
24.Overflow incontinence
25.I can teach you strategies to help control your incontinence
26.Make an appointment with your provider
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