The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions."

Question

Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan?

A) Encouraging the client to consume two to three quarts of clear fluids daily
B) Creating an environment that is likely to reduce anxiety
C) Positioning the client supine
D) Encouraging the client to decrease the number of cigarettes smoked daily

Answer 1

Ans: A
Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler's position.