Author Question: The nurse is planning care to address ineffective airway clearance for a client with lung cancer. ... (Read 43 times)

colton · **on:** Jun 25, 2018

The nurse is planning care to address ineffective airway clearance for a client with lung cancer. Which interventions should the nurse include in the client's plan of care? Select all that apply.

A) Increase fluid intake to 3000 mL per day.
B) Turn, cough, and deep breathe every 2 hours.
C) Chest percussion every 8 hours
D) Smoking cessation education
E) Administer pneumococcal vaccine.

Question 2

An older adult client with terminal lung cancer is not breathing well and has cold and mottled skin. The client has a living will and requests comfort measures only. What should the nurse do to help this client?

A) Ask the family what they want to be done for the client.
B) Withhold all care until the client dies.
C) Contact the physician for orders to control the client's breathing.
D) Provide the client with pain medication as ordered.

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

Answer to Question 1

Answer: A, B, C

An adequate fluid intake is needed. Clients with pneumonia should increase their fluid intake in order to decrease the viscosity of respiratory secretions. Turning, coughing, deep breathing and chest percussion can help clear secretions. Administering the pneumococcal vaccine and educating the client on smoking cessation are important in treating a client with pneumonia, but they would be aligned with a different nursing diagnosis.

Answer to Question 2

Answer: D

Comfort measures only indicates that the client does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide client comfort is intensified and maintained through the end stages of the client's life. Nursing care will include the administration of pain medication and providing personal hygiene and nutrition. Asking the family what they want to be done is inappropriate when a client has written a living will. Contacting the physician to intervene to control respiration is considered adding extraordinary measures and is inappropriate, as is going against the client's written wishes when a living will is present and in force.