Author Question: A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway ... (Read 133 times)

bobypop · **on:** Jun 25, 2018

A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action is a priority for the nurse to include in the plan of care?

a. Encourage use of the incentive spirometer.
b. Offer the patient fluids at frequent intervals.
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation >93.

Question 2

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?

a. Elevate head of bed to 30 to 45 degrees.
b. Suction the endotracheal tube every 2 to 4 hours.
c. Limit the use of positive end-expiratory pressure.
d. Give enteral feedings at no more than 10 mL/hr.

sarahccccc · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) in order to facilitate the clearance of the secretions. The other actions may also be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

Answer to Question 2

ANS: A
Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs.