A patient, recovering from thoracic surgery, is demonstrating evidence of impaired gas exchange with a dropping oxygen saturation level. Which of the following interventions would be appropriate for the patient at this time?
1. Splint the chest when coughing.
2. Turn every 2 hours and coach to use the incentive spirometer every 1 to 2 hours.
3. Encourage fluids up to 2.5 liters per day.
4. Suction as necessary.
2
Rationale: Interventions appropriate for a patient with impaired gas exchange include turning every 2 hours, encourage spirometer use every 1 to 2 hours, elevate head of bed greater than 30 degrees, monitor effects of pain medication therapy, assist to a sitting position, and encourage early ambulation. Using a splint with coughing will help reduce pain. Encouraging fluids and suctioning as necessary would be essential for the patient with ineffective airway clearance.
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