A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations
Which nursing intervention should be listed first on the care plan?
a. Determine airway adequacy hourly and as needed.
b. Administer oxygen as needed.
c. Monitor arterial blood gas values.
d. Place the client in a high Fowler's position.
A
For any acute respiratory problem, prior to implementing interventions the nurse would assess breathing status of the patient by checking the respiratory rate and depth. When devising a plan of care for the client, nursing interventions should be listed according to priority. Airway always takes precedence, as ventilation, oxygenation, and positioning will be ineffective without a patent airway.
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