The nursing diagnosis Ineffective Airway Clearance has been identified for a patient with multiple sclerosis. Which interventions should the nurse include in this patient's plan of care? (Select all that apply.)

Question

a. Measure intake and output
b. Elevate the head of the bed
c. Evaluate gag reflex every shift
d. Monitor oxygen saturation twice a shift
e. Encourage deep breathing and coughing every 2 hours

Answer 1

ANS: B, C, D, E
Nursing interventions appropriate for the patient with Ineffective Airway Clearance include elevating the head of the bed, evaluating gag reflex every shift, monitoring oxygen saturation twice a shift, and encouraging deep breathing and coughing every 2 hours. A. Intake and output measurement would be more appropriate for the patient with a fluid volume imbalance.