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1. Counts respiratory rate and observes respiratory effort; auscultates lung fields.
2. Collaborates with RN to make diagnosis of Ineffective breathing pattern related to positioning that prevents lung expansion.
3. Identifies outcome of "patient will demonstrate respiratory rate of 12-20 breaths/min after being positioned in high Fowler's."
4. Assist RN to develop a plan of care that will improve the patient's ability to breathe and expand lungs.
5. Assists to high Fowler's position or assists to sit in the bedside chair.
6. Checks oxygen saturation and asks patient about subjective feelings of relief after being repositioned.
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Which best describes the diagnosis step of the nursing process?
The nurse gathers patient data through observation, interviews, and physical assessment.
The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers.
The nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused with specific outcomes.
The nurse initiates specific nursing interventions and treatments designed to help the patient achieve established goals and outcomes.
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