A patient with pneumonia is having difficulty maintaining a clear airway. Which actions should the nurse take to ensure this patient is adequately ventilated?
Select all that apply.
1. Assess skin color at least every four hours.
2. Assess breath sounds at least every four hours.
3. Assess oxygen saturation level at least every four hours.
4. Assess vital signs daily.
5. Assess respiratory rates every shift.
Correct Answer: 1, 2, 3
When monitoring a patient with a respiratory illness that induces secretions, the patient must be monitored for ineffective airway clearance. By assessing the skin, vital signs, breath sounds, and oxygen saturation levels at least every four hours, the nurse will be able to detect subtle changes that could indicate impending changes with the patient. Respiratory rates must be assessed on a frequency level similar to the breath sounds assessment, if not more often.
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