One of the nursing actions includes turning, coughing, and deep breathing the client every 2 hours; what assessment is needed to validate the effectiveness of these actions?
1. Assessment of bilateral lung sounds
2. Documenting the blood pressure to compare the trends
3. Monitoring intake and output
4. Assess carotid pulses for bruits
Assessment of bilateral lung sounds
Rationale: Assessment of bilateral lung sounds will evaluate the effectiveness of pulmonary exchanges of air and the possible fluid buildup that would diminish or prevent air flow in the bases of the lungs from atelectasis. Trending the blood pressures will show hemodynamic status but does not address the atelectasis and pulmonary functions that are directly related to the actions of turning, coughing, and deep breathing. Monitoring intake and output will show fluid status that increases the risk of fluids in the lungs but will not be improved by the actions of turning, coughing, and deep breathing. Assessment of the carotid pulses for bruits is used to show vascular status and is not impacted by pulmonary status that is related to turning, coughing, and deep breathing.
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