Medical Surgical Myocardial Infarction #4

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:

      This answer is not correct because although a low sodium diet is important for this client, it does not address the nursing diagnosis of ineffective airway clearance related to pulmonary secretions. The client should be taught and produce return demonstration about deep breathing and coughing exercises to help produce a patent airway with adequate gas exchange.

  2. Client teaching and demonstration of self-injection of enoxaparin
    • Rationale:

      This answer is not correct because teaching and demonstration of self-injection of enoxaparin is related to decreasing deep vein thrombosis, not ineffective airway clearance related to pulmonary secretions. The client should be taught and produce return demonstration about deep breathing and coughing exercises to help produce a patent airway with adequate gas exchange.

  3. Client teaching on the need for weekly PTT and INR for enoxaparin therapy
    • Rationale:

      This answer is not correct because teaching on the need for weekly PTT and INR for enoxaparin therapy is not needed and does not address the nursing diagnosis of ineffective airway clearance related to pulmonary secretions. The client should be taught and produce return demonstration about deep breathing and coughing exercises to help produce a patent airway with adequate gas exchange.

  4. Client teaching and demonstration of deep breathing and coughing exercises
    • Rationale:

      This answer is correct because the client should be taught and return demonstration about deep breathing and coughing exercises to help produce a patent airway with adequate gas exchange. Ineffective airway clearance is the difficulty or inability to clear or remove pulmonary secretions or excretions from the airway or bronchi. Being able to keep the airway patent is vital to life. A history of smoking can increase the risk of being unable to clear secretions from the airway. Ineffective airway clearance is characterized by dyspnea, excess secretions, ineffective or no cough, cyanosis, abnormal respirations, and adventitious (abnormal) breath sounds.

Overview

Ineffective airway clearance is the difficulty or inability to clear or remove pulmonary secretions or excretions from the airway or bronchi. The nurse should teach and have the client who has a history of smoking and is two days post-cardiac surgery to indicate understanding by demonstration about deep breathing and coughing exercises.

Explanation

Learning Outcomes

Ineffective airway clearance is the difficulty or inability to clear or remove pulmonary secretions or excretions from the airway or bronchi. Being able to keep the airway patent is vital to life. A history of smoking can increase the risk of being unable to clear secretions from the airway. Ineffective airway clearance is characterized by dyspnea, excess secretions, ineffective or no cough, cyanosis, abnormal respirations, and adventitious (abnormal) breath sounds. Following any heart or chest surgery, the client will be at more risk for breathing difficulties, especially with a history of smoking. The client should be taught and produce return demonstration about deep breathing and coughing exercises to help produce a patent airway with adequate gas exchange.

Test Taking Tip

When answering a question, always read and re-read (as many times as you need) the question’s stem and any associated, pertinent information. You must answer what the question is asking so do not get distracted.

Video Rationale