The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is:
a. Elevate head of bed to 30 degrees.
b. Obtain order for venous thromboembolism prophylaxis.
c. Provide adequate sedation.
d. Reposition patient every 2 hours.
D
Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions.
You might also like to view...
A patient with a progressive neurological disease wants to visit shrines in the United States to offer prayers for healing. Which shrines would be available for the patient to visit?Select all that apply.Note: Credit will be given only if all correct choices and no incorrect choices are selected.
A. The Tomb of Menachem Mendel Schneerson B. Shrine of Our Lady of San Juan C. Shrine of our Lord of Esquipulas D. The National Shrine of Our Lady of the Snows E. The Shrine of our Lady of Montserrat
When performing a physical examination of a client's skin, the nurse should:
1. Be aware of ethnic differences. 2. Examine the least-exposed areas first. 3. Inspect the skin while the client is standing up. 4. Examine only the areas of specific concern.
A community health nurse is developing health promotion programs for a local community that consists predominantly of African Americans. Which of the following areas would be a priority for health promotion with this group?
A) Cardiac health B) Respiratory care C) Mental health D) Skin care
A nurse is just starting a job at a new hospital. As part of the orientation process, the nurse must review the hospital's policies and procedures for nursing care
Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff for which of the following reasons? (Select all that apply.) 1. Make sure all clients have the same types of care 2. Ensure that minimally accepted standards are met 3. Promote efficient use of the nurse's time 4. Eliminate care disparities among clients