Impaired gas exchange diagnosis was present in 42.6% of the children in the first assessment. high-pitched and inspiratory crackles (rales) that are amplified by coughing or heard only after coughing. Use a sterile catheter for each suctioning procedure. c. Keep a same-size or larger replacement tube at the bedside. The immunity will not protect for several years, as new strains of influenza may develop each year. A) Seizures associated with increased fluid loss in the presence of tachypnea, fever, or diaphoresis Desired outcome: at least 24 hours before hospital discharge, the patient is normovolemic, i.e., has a urine output of 30 mL/h or greater, stable weight, heart rate less than 100 bpm, blood pressure greater than 90 mm Hg, fluid intake equal to fluid excretion, moist mucous membranes, and normal skin turgor. Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. Nursing care plan for impaired gas exchange. Help the patient get into a comfortable position, usually the half-Fowler position. The nurse identifies which factor that places a patient at risk for aspiration pneumonia? It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. Discontinue if SpO2 level is above the target range, or as ordered by the physician. Learning to apply information through a return demonstration is more helpful than verbal instruction alone. The patient is positioned and instructed not to talk or cough to avoid damage to the lung. g. Fine crackles When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? 6. b. So to avoid that, they must be assisted in any activities to help conserve their energy. Because antibody production in response to infection with the tuberculosis (TB) bacillus may not be sufficient to produce a reaction to TB skin testing immediately after infection, 2-step testing is recommended for individuals likely to be tested often, such as health care professionals. Smoking further increases the risk of developing pneumonia and should be avoided. Pneumonia may increase sputum production causing difficulty in clearing the airways. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). c. Mucociliary clearance Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. Select all that apply. A) Teaching the patient how to cough effectively and. Inspection d. Inform the patient that radiation isolation for 24 hours after the test is necessary. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days. In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. Retrieved February 9, 2022, from, Testing for Sepsis. The patient must understand the importance of seeing an attending physician and not rely on what they see or hear on the internet. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). What action should the nurse take? Assess the need for hyperinflation therapy. These interventions help facilitate optimum lung expansion and improve lungs ventilation. ineffective airway clearance related to pneumonia and copd impaired gas exchange related to acute and chronic lung. Empyema is a collection of pus in the thoracic cavity. Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). To assess the extent and symmetry of chest movement, the nurse places the hands over the lower anterior chest wall along the costal margin and moves them inward until the thumbs meet at the midline and then asks the patient to breathe deeply and observes the movement of the thumbs away from each other. 1. Nursing Diagnosis: Hyperthermia related to the disease process of bacterial pneumonia as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, and profuse sweating. Nursing Diagnosis: Ineffective Airway Clearance. The nurse expects which treatment plan? This type of pneumonia refers to getting the infection at home, in the workplace, in school, or other places in the community outside a hospital or care facility. A patient with an acute pharyngitis is seen at the clinic with fever and severe throat pain that affects swallowing. Discharge from the hospital is expected if the patient has at least five of the following indicators: temperature 37.7C or less, heart rate 100 beats/minute or less, heart rate 24 breaths/minute or less, systolic blood pressure (SBP) 90 mm Hg or more, oxygen saturation greater than 92%, and ability to maintain oral intake. What the oxygenation status is with a stress test 3. presence of nasal bleeding and exhalation grunting. 4. a. c. Decreased chest wall compliance Identify and avoid triggers of the allergic reaction. Increased fluid intake decreases viscosity of sputum, making it easier to lift and cough up. The patients blood oxygen saturation (SpO2) will also be within the target levels set by the physician (usually 96 to 100 percent; 88 to 92% for most. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Health perception-health management: Tobacco use history, gradual change in health status, family history of lung disease, sputum production, no immunizations for influenza or pneumococcal pneumonia received, travel to developing countries Priority Decision: A 75-year-old patient who is breathing room air has the following arterial blood gas (ABG) results: pH 7.40, partial pressure of oxygen in arterial blood (PaO2) 74 mm Hg, arterial oxygen saturation (SaO2) 92%, partial pressure of carbon dioxide in arterial blood (PaCO2) 40 mm Hg. The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment. Retrieved February 9, 2022, from, Pneumonia: Symptoms, Treatment, Causes & Prevention. Retrieved February 9, 2022, from. a. Suction the tracheostomy. b. Related to: As evidenced by: Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. d. Patient can speak with an attached air source with the cuff inflated. Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. Use only sterile fluids and dispense with sterile technique. Touching an infected object and then touching your nose or mouth can also transfer the germs. The patient will have a big chance to remember how to administer or perform any therapeutic regimen if they are given the chance to demonstrate and have him/her verbalize their understanding about it. Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. To avoid the formation of a mucus plug, suction it as needed. Findings may show hypoxemia (PaO2 less than 80 mm Hg) and hypocarbia (PaCO2 less than 32-35 mm Hg) with resultant respiratory alkalosis (pH greater than 7.45) in the absence of underlying pulmonary disease. A) Increasing fluids to at least 6 to 10 glasses/day, unless. Assess lung sounds and vital signs. Oxygen is administered when O2 saturation or ABG results show hypoxemia. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? d. Activity-exercise With severe pneumonia, the patient needs a higher level of care than general medical-surgical. (2020). These interventions contribute to adequate fluid intake. Volcanic eruptions and other natural events result in air pollution. Always wear gloves on both hands for suctioning. was admitted, examination of his nose revealed clear drainage. b. Consider sources of infection.Any inserted lines such as IVs, urinary catheters, feedings tubes, suction tubing, or ventilation tubes are potential sources of infection. What should the nurse do when preparing a patient for a pulmonary angiogram? She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. a. Apex to base Usually, people with pneumonia preferred their heads elevated with a pillow. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. k. Value-belief: Noncompliance with treatment plan, conflict with values, The abnormal assessment findings of dullness and hyperresonance are found with which assessment technique? It is very important to take and record the patients respiratory assessment to make it a basis if there are any abnormal findings in the future. b. Nutritional-metabolic: Decreased fluid intake, anorexia and rapid weight loss, obesity Hospital acquired pneumonia may be due to an infected. d. Normal capillary oxygen-carbon dioxide exchange. Are there any collaborative problems? NMNEC Concept: Gas Exchange. b. 8. It can have too much oxygen or carbon dioxide in the body which is not very beneficial to the organs or systems. Priority: Sleep management If there are some questions or clarifications when it comes to their medicines, make sure to find time to explain to him/her so that this will ensure compliance with the treatment. Periorbital and facial edema reduced by about half since second hospital day Nursing Diagnosis. 1) The cough may last from 6 to 10 weeks. Given a square matrix [A], write a single line MATLAB command that will create a new matrix [Aug] that consists of the original matrix [A] augmented by an identity matrix [I]. c. Send labeled specimen containers to the laboratory. Pneumonia Nursing Care Plan 4 Impaired Gas Exchange Nursing Diagnosis: Impaired Gas Exchange related to the overproduction of mucus in the airway passage secondary to pneumonia as evidenced by cyanosis, restlessness, and irritability. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. To help clear thick phlegm that the patient is unable to expectorate. Building up secretions in the airway will only cause a problem since it will obstruct the airflow from going in and out of the body. c. Terminal structures of the respiratory tract Line the lung pleura 6. Put the index fingers on either side of the trachea. Please follow your facilities guidelines, policies, and procedures. Promote skin integrity.The skin is the bodys first barrier against infection. b. impaired gas exchange nursing care plan scribd. Why does a patient's respiratory rate increase when there is an excess of carbon dioxide in the blood? document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. What is the best response by the nurse? Allow 90 minutes for. c. Elimination: Constipation, incontinence b. RV St. Louis, MO: Elsevier. Saunders comprehensive review for the NCLEX-RN examination. Etiology The most common cause for this condition is poor oxygen levels. g. Self-perception-self-concept: Chest pain or pain with breathing Inability to maintain lifestyle, altered self-esteem Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case. Popkin, B. M., DAnci, K. E., & Rosenberg, I. H. (2010). The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? Reporting complications of hyperinflation therapy to the health care provider. Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? In addition, have the patient upright and leaning forward to prevent swallowing blood. The thoracic cage is formed by the ribs and protects the thoracic organs. Document the results in the patient's record. Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. Expresses concern about his facial appearance The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. Desired Outcome: At the end of the span of care, the patient will be able to understand the transmission, disease process, and available treatments for pneumonia. Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy (see Table 25.10). b. Palpation It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. 4) Cough suppressants and antihistamines should not be used. i. Sexuality-reproductive Decreased skin turgor and dry mucous membranes as a result of dehydration. 3.2 Impaired Gas Exchange. d. CO2 directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume. This produces an area of low ventilation with normal perfusion. d. Direct the family members to the waiting room. b. d. Pleural friction rub. b. 3. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public. Amount of air that can be quickly and forcefully exhaled after maximum inspiration Activity intolerance 2. Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. Examine sputum for volume, odor, color, and consistency; document findings. Identify up to what extent does the patient knows about pneumonia. Pneumonia will be one of the most frequent infections the nurse will encounter and treat. b. The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. What is the first action the nurse should take? Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. The bacteria may enter the blood stream and cause, Trouble sleeping. 1. The most common. The other options contribute to other age-related changes. Factors that increase the risk of nosocomial pneumonia in surgical patients include: older adults (older than 70 years), obesity, COPD, other chronic lung diseases (e.g., asthma), history of smoking, abnormal pulmonary function tests (especially decreased forced expiratory flow rate), intubation, and upper abdominal/thoracic surgery. Medical-surgical nursing: Concepts for interprofessional collaborative care. Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. e. Rapid respiratory rate. The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. 1. Make sure to avoid flowers, strong smell scents, dust, and other allergens that are present in the room. e. Sleep-rest: Sleep apnea. Fever reducers and pain relievers. a. b. It is important to acknowledge their limited information about the disease process and start educating him/her from there. b. a hemilaryngectomy that prevents the need for a tracheostomy. This is most common in intensive care units usually resulting from intubation and ventilation support. b. SpO2 of 95%; PaO2 of 70 mm Hg On inspection, the throat is reddened and edematous with patchy yellow exudates. Pleural friction rub occurs with pneumonia and is a grating or creaking sound. The width of the chest is equal to the depth of the chest. d) 8. Put the palms of the hands against the chest wall. Air trapping Cancer of the lung General physical assessment findingsof pneumonia. What is the first patient assessment the nurse should make? The width of the chest is equal to the depth of the chest. 1) b. Corticosteroids and bronchodilators are not useful in reducing symptoms. d. Thoracic cage. Obtain the supplies that will be used. c. Tracheal deviation Pinch the soft part of the nose. Expected outcomes Patient who is anesthetized b. Air trapping Mixed venous blood gases are used when patients are hemodynamically unstable to evaluate the amount of oxygen delivered to the tissue and the amount of oxygen consumed by the tissues. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. d. Apply an ice pack to the back of the neck. cancer patients or COPD patients). Bronchoconstriction g) 4. Apply pressure to the puncture site for 2 full minutes. Viruses such as RSV (common cause in infants age 1 and below), flu and cold viruses can cause viral pneumonia, which is the second most common type of pneumonia. A closed-wound drainage system A combination of excess CO2 and H2O results in carbonic acid, which lowers the pH of cerebrospinal fluid and stimulates an increase in the respiratory rate. Signs and Symptoms of impaired gas exchange dyspnea, SOB cough hemoptysis: coughing up blood abnormal breathing patterns: tachypnea, diabetic ketoacidosis, kusbal respirations (diabetic ketoacidosis leads to hypoxemia through kusbal resp trying to get rid of extra CO2) hypoventilation hyperventilation cyanosis (late sign) The pH is also decreased in mixed venous blood gases because of the higher partial pressure of carbon dioxide in venous blood (PvCO2). When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? 3 Pneumonia in the immunocompromised individual 4 Assessment of pneumonia 5 Diagnostic test for pneumonia 6 Nursing Diagnosis of pneumonia 6.1 Risk for Infection (nosocomial pneumonia) 6.2 Impaired Gas Exchange due to pneumonic condition 6.3 Ineffective clearance of the airway 6.4 Deficient fluid volume Community acquired pneumonias 5. The patient has been diagnosed with an early vocal cord cancer. This intervention provides oxygenation while reducing convective moisture loss and helping to mobilize secretions. a. Thoracentesis 25: Assessment: Respiratory System / CH. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. a. What are possible explanations for this behavior? While the nurse is feeding a patient, the patient appears to choke on the food. 4) Spend as much time as possible outdoors. What should be the nurse's first action? a. Primary care, with acute or intensive care hospitalization due to complications. If there is no improvement with the symptoms, the doctor may prescribe a different type of antibiotic. Hypoxemia was the characteristic that presented the best measures of accuracy. Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. As the patients condition worsens, sputum may become more abundant and change color from clear/white to yellow and/or green, or it may exhibit other discolorations characteristic of an underlying bacterial infection (e.g., rust-colored; currant jelly). If there is airway obstruction this will only block and cause problems in gas exchange. It may also cause hepatitis. The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. d. Patient receiving oxygen therapy. Priority Decision: F.N. Nursing Diagnosis: Ineffective Airway Clearance related to the disease process of bacterial pneumonia as evidenced by shortness of breath, wheeze, SpO2 level of 85%, productive cough, difficulty to expectorate greenish phlegm. Stop feeding when the patient is lying flat. d. Testing causes a 10-mm red, indurated area at the injection site. Let the patient do a return demonstration when giving lectures about medication and therapeutic regimens. Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of carbon dioxide from cells into the blood, resulting in a much lower PaO2 and an increased PaCO2. These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. c. There is equal but diminished movement of the 2 sides of the chest. Promote fluid intake (at least 2.5 L/day in unrestricted patients). Decreased compliance contributes to barrel chest appearance. b. Impaired Gas Exchange is a NANDA nursing diagnosis that is used for conditions where there is an alteration in the balance between the exchange of gases in the lungs. c. Take the specimen immediately to the laboratory in an iced container. Pulse oximetry would not be affected by fever or anesthesia and is a method of monitoring arterial oxygen saturation in patients who are receiving oxygen therapy. What is the most appropriate action by the nurse? a. treatment with antibiotics. Antibiotics: To treat bacterial pneumonia. It reduces the pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. When obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? c. Persistent swelling of the neck and face Tuberculosis frequently presents with a dry cough. b. CO2 causes an increase in the amount of hydrogen ions available in the body. (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. d. An ET tube is more likely to lead to lower respiratory tract infection. The nurse is preparing the patient for and will assist the health care provider with a thoracentesis in the patient's room. Which age-related changes in the respiratory system cause decreased secretion clearance (select all that apply)? Severe pneumonia can be life-threatening for patients who are very young, very old (age 65 and above), and immunocompromised (e.g. Alveolar-capillary membrane changes (inflammatory effects) The arterial oxygen saturation by pulse oximetry (SpO2) compared with normal values will not be helpful in this older patient or in a patient with respiratory disease as the patient's expected normal will not be the same as standard normal values. Viral pneumonia. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. Antibiotics. During a follow-up visit one week after starting the medication, the patient tells the nurse, "In the last week, my urine turned orange, and I am very worried about it." The nurse suspects which diagnosis? If the probe is intact at the site and perfusion is adequate, an ABG analysis will be ordered by the HCP to verify accuracy, and oxygen may be administered, depending on the patient's condition and the assessment of respiratory and cardiac status. The patient will also be able to reach maximum lung expansion with proper ventilation to keep up with the demands of the body. Patients with compromised immune systems such as those with COPD, HIV, or autoimmune diseases should be educated on the risk and how to protect themselves. Impaired Gas Exchange Assessment 1. Change the tube every 3 days. Rest lowers the oxygen demand of a patient whose reserves are likely to be limited. Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. Discussion Questions The most common causes of community-acquired pneumonia (CAP) is S. pneumoniae followed by Klebsiella pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa. Assess the patients vital signs and characteristics of respirations at least every 4 hours. f) 2. Coughing and difficulty of breathing may cause. Individuals with depressed level of consciousness, advanced age, dysphagia, or a nasogastric (NG) or enteral tube are at increased risk for aspiration, which predisposes them to pneumonia. c. It has two tubings with one opening just above the cuff. CH. Watch for signs and symptoms of respiratory distress and report them promptly. Blood culture and sensitivity: To determine the presence of bacteremia and identify the causative organism. 4. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. b. A) Purulent sputum that has a foul odor d. Parietal pleura. Respiratory distress requires immediate medical intervention. Promote a well-ventilated environment so that the patient will have good oxygen exchange in the body. Steroids: To reduce the inflammation in the lungs. Always change the suction system between patients. Consider imperceptible losses if the patient is diaphoretic and tachypneic. f. PEFR Assess the patients vital signs at least every 4 hours. Patient with a fever Base to apex The turbinates in the nose warm and moisturize inhaled air. d. Oxygen saturation by pulse oximetry c. Patient in hypovolemic shock What do these findings indicate? patients with pneumonia need assistance when performing activities of daily living. With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. d. Small airway closure earlier in expiration What accurately describes the alveolar sacs? Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. A third type is pneumonia in immunocompromised individuals. is a 28-year-old male patient who sustained bilateral fractures of the nose, 3 rib fractures, and a comminuted fracture of the tibia in an automobile crash 5 days ago. a. e. Observe for signs of hypoxia during the procedure. Nurses also play a role in preventing pneumonia through education. A patient's initial purified protein derivative (PPD) skin test result is positive. Water, hydration, and health. Acid-fast stains and cultures: To rule out tuberculosis. Atelectasis 1# Priority Nursing Diagnosis. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Lung abscess. Turbinates warm and moisturize inhaled air. It is important to assess the ability of the patient to do self-care ost especially if he or she is having respiratory symptoms. Outcomes are influenced by the age of the patient, the extent of the disease process, the underlying disease, and the pathogen involved. Nursing Diagnosis: Ineffective Breathing Pattern related to decreased lung expansion secondary to pneumonia as evidenced by a respiratory rate of 22, usage of accessory muscles, and labored breathing. Which values indicate a need for the use of continuous oxygen therapy? How does the nurse assess the patient's chest expansion? d. Bradycardia Assist the patient with position changes every 2 hours. Airway obstruction is most often diagnosed with pulmonary function testing. 3) Illicit drug intake b. treatment with antifungal agents. Assist the patient when they are doing their activities of daily living. e) 1. COPD ND3: Impaired gas exchange. Auscultation of breath sounds every 2 to 4 hours (or depending on the patients condition) and reporting of changes in the patients ability to secrete lung secretions. The nurse provides care for a patient with a suspected lung abscess and expects which assessment finding? Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Monitor for worsening signs of infection or sepsis.Dropping blood pressure, hypothermia or hyperthermia, elevated heart rate, and tachypnea are signs of sepsis that require immediate attention. Bronchoconstriction c. Patient in hypovolemic shock Recognize the risk factors for infection in patients with tracheostomy and take the following actions: Risk factors include the presence of underlying pulmonary disease or other serious illness, increased colonization of the oropharynx or trachea by aerobic gram-negative bacteria, increased bacterial access to the lower airway, and cross-contamination from manipulation of the tracheostomy tube.
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