Respiratory Question #7

Question

The nurse plans for a nursing diagnosis of ineffective airway clearance for a client with pneumonia. Which intervention will the nurse identify as a priority in the plan of care?

Answers

1. Instruct on coughing, deep breathing, and hydration.
   • Rationale:
2. Give the client supplemental oxygen.
   • Rationale:
3. Contact physician for blocked airway and prepare tracheostomy set-up.
   • Rationale:
4. Client will maintain head of bed in mid-fowlers for the next 48 hours.
   • Rationale:

Overview

Explanation

Coughing and deep breathing along with maintaining adequate hydration are important for achieving effective airway clearance. Selection B is not a priority for the plan of care for airway clearance needs since it does not affect airway as a priority like coughing/deep breathing and hydration (which will help mobilize secretions) Oxygenation helps with diagnoses of impaired gas exchange and ineffective breathing related to abnormal oxygenation/carbon dioxide ratio. Selection C is unnecessary for a priority when other less invasive interventions are available. Selection D is stated as a goal/outcome, not an intervention. (HINT: Make sure question stems and answers on the nursing process coincide)

Learning Outcomes

Test Taking Tip

Video Rationale