Brunner & Suddarth's Textbook of Medical-Surgical Nursing 13th Edition by Kerry Cheever, Janice Hinkle

Exercise 2

An 85-year-old woman is being admitted to your unit from a long-term carefacility.She had a CVA 5 years ago with subsequent persistent right-sided flaccidparalysis.She has a gastrostomy tube that is clamped.From the brief report youreceived, you know she was receiving enteral tube feedings at 60 mL per hour. She issupine in bed, is awake, and her face is flushed. She has the following vital signs: BP,104/60; pulse, 110 bpm; respiratory rate, 30 breaths/min; temperature, 38.8°C(101.8°F). What risk factors does she have for developing pneumonia? What type ofbreath sounds might you expect to hear when auscultating her lungs? Identify fivepriority nursing interventions to treat her nursing diagnosis of Ineffective airwayclearance.