A nurse is providing care for a patient with Ineffective Airway Clearance. Which are appropriate interventions to address this problem? (Select all that apply.)
a. Weigh patient every day.
b. Teach patient proper use of an incentive spirometer.
c. Place patient in supine position and turn every 2 hours.
d. Assess respiratory rate and pattern every 4 hours and prn.
e. Encourage patient to deep breathe and cough every 2 hours.
f. Administer guaifenesin (Mucinex) every 4 to 6 hours prn as ordered.
ANS: A, B, C, D, E, F
Interventions to help with ineffective airway clearance include teaching the use of incentive spirometry, assessing respiratory rate and pattern every 4 hours and as needed, encouraging the patient to deep breathe and cough every 2 hours, and administering medication to thin secretions as prescribed. A. Daily weights may be done for other reasons but are not directly related to the problem of ineffective airway clearance.
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