Cardiac Question #28

Question

The nurse is preparing an individualized education plan for a client who has a history of smoking and is two days post cardiac surgery. Which information best addresses client education as an intervention for the nursing diagnosis of ineffective airway clearance related to pulmonary secretions?

Answers

  1. Client Teach-Back on low sodium diet
    • Rationale:
  2. Client teaching and demonstration of self-injection of lenoxaparin (Lovenox)
    • Rationale:
  3. Client teaching on the need for weekly PTT and INR for lenoxaparin therapy
    • Rationale:
  4. Client teaching and demonstration of deep breathing and coughing exercises
    • Rationale:

Overview

Explanation

Since the client has a history of smoking, and the nursing diagnosis addresses ineffective airway clearance, the best choice is teaching and demonstration of deep breathing and coughing exercises. Breathing adequately assists in moving air to the lung bases, opens air passages, and helps mobilize mucous through effective coughing. Deep breathing and coughing also helps the blood and oxygen supply to the lungs, improving circulation. The client has risk factors of smoking, thus an important priority will be to assist with deep breathing/coughing. While low sodium diet is important, the nursing diagnosis and interventions are related to airway clearance. The question stem does not mention self-injection of lenoxaparin, and the client may be receiving a different type of anticoagulant while in the hospital setting. Weekly PTT and INR are not needed with low molecular weight heparin.

Learning Outcomes

Test Taking Tip

Video Rationale