The client's nursing diagnoses include Risk for ineffective airway clearance related to decreased respiratory effort postoperatively. Which specific client assessment data should the nurse monitor in the client's plan of care?
1. Peak expiratory flow rate at 2% less than the client baseline
2. Nasal flaring and intercostal retractions with each inspiration
3. Frequent coughing and large amounts of clear, watery sputum
4. Arterial blood gases reveal PaO2 97 mm Hg and PaCO2 37 mm Hg
2
2. The nurse specifically monitors for nasal flaring and accessory muscle use during inspiration because these indicate the client needs additional oxygen and is working very hard to breathe. Clients cannot breathe in this manner for long periods because the muscles become fatigued and respiratory failure develops. The nurse addresses nasal flaring and use of accessory muscles promptly to avoid client deterioration.
1. A peak expiratory flow rate within 2% of baseline is acceptable because it indicates that the client is able to exhale at a rate within 2% of the client's normal rate.
3. Frequent coughing that produces thin, clear secretions facilitates airway clearance and is highly desirable in the postoperative period.
4. The ABGs are within normal limits and the nurse expects blood gases within nor-mal limits.
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