Author Question: He nurse is planning care for a client with respiratory acidosis who is experiencing ineffective ... (Read 89 times)

daltonest1984 · **on:** Jun 25, 2018

he nurse is planning care for a client with respiratory acidosis who is experiencing ineffective airway clearance. What interventions should the nurse include in this client's plan of care? (Select all that apply.)

1. Provide chest physiotherapy
2. Coach to breathe into a paper bag
3. Encourage frequent position changes
4. Instruct in the use of pursed lip breathing
5. Suggest increasing oral fluids to 3 L per day

Question 2

A 53-year-old client asks the nurse to explain why there is shoulder pain when the gallbladder has stones. The best response by the nurse is:

1. This type of pain is known as referred pain, and is normal.
2. This type of pain increases pain tolerance.
3. Referred pain helps you perceive pain sooner.
4. Abnormal neurons in the body cause referred pain.

Silverbeard98 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: 1, 3, 4, 5

1. Chest physiotherapy through percussion, vibration, and postural drainage helps loosen respiratory secretions so they can be coughed out of airways.
2. Having the patient breathe into a paper bag is effective for an ineffective breathing pattern.
3. Frequent position changes promote airway clearance and lung expansion.
4. Pursed-lip breathing helps maintain open airways throughout exhalation, promoting carbon dioxide elimination.
5. Fluid intake of up to 3,000 mL/day helps liquefy secretions and hydrate respiratory mucous membranes, promoting airway clearance.

Answer to Question 2

Answer: 1

1. Referred pain starts in one area of the body, but is felt in another, and is a normal pain process.
2. Pain tolerance is individual and is the amount and duration of pain that each individual can tolerate before seeking relief. Pain tolerance is not affected by referred pain.
3. Referred pain does not affect the perception of pain. On the contrary, the client might not seek treatment for shoulder pain that is actually of cardiac origin.
4. Abnormal neurons in the body are not the cause of referred pain. They are more likely to decrease perception of pain.