NURSE-UN 240 Lecture Notes - Lecture 5: Modes Of Mechanical Ventilation, Fremitus, Occlusive Dressing
10 Nov 2018
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Document Summary
The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance: basilar crackles, oxygen saturation of 85, rationale: accumulation of secretions in the lower airways, the nurse is performing a respiratory assessment for a patient admitted with pneumonia. Increased vocal fremitus on palpation: fine crackles in all lobes on auscultation, rationale: crackles only in affected areas, the nurse is caring for a patient with ineffective airway clearance. Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on 3 sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing: the nurse is caring for a patient with an alteration in airway clearance.
