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Author Question: What intervention does the nurse identify as the priority for the client with a nursing diagnosis of ... (Read 74 times)

ss2343

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What intervention does the nurse identify as the priority for the client with a nursing diagnosis of ineffective airway clearance related to the flu?
 
  1. Provide supplemental oxygen
   2. Keep the head of the bed elevated
   3. Teach the client coughing, deep breathing, and hydration
   4. Prepare the client for the possibility of a tracheostomy tube

Question 2

The nurse instructed a client on ways to reduce premenstrual difficulty. Which of the following would indicate the instruction was beneficial?
 
  1. The client states the need to increase dietary sugar intake to promote energy.
   2. The client states the need to increase intake of simple carbohydrates.
   3. The client states reducing caffeine will help.
   4. The client states guided imagery does not help with the symptoms.



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amynguyen1221

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Answer to Question 1

3. Teach the client coughing, deep breathing, and hydration
Rationale:
Coughing, deep breathing, and, hydration are essential for achieving airway clearance. Insertion of a tracheostomy and oxygen are not primary treatments for ineffective airway clearance. Elevating the head of the bed may assist the client but is not sufficient without additional interventions.

Answer to Question 2

3. The client states reducing caffeine will help.

Rationale:
The client stating that a reduction in caffeine intake will help is evidence that instruction was beneficial. The other client statements would indicate the need for additional instruction since guided imagery can be used to reduce stress and promote relaxation, and simple carbohydrates and sugars should be reduced.





 

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