What intervention does the nurse identify as the priority for the client with a nursing diagnosis of ineffective airway clearance related to the flu?
1. Provide supplemental oxygen
2. Keep the head of the bed elevated
3. Teach the client coughing, deep breathing, and hydration
4. Prepare the client for the possibility of a tracheostomy tube
3. Teach the client coughing, deep breathing, and hydration
Rationale:
Coughing, deep breathing, and, hydration are essential for achieving airway clearance. Insertion of a tracheostomy and oxygen are not primary treatments for ineffective airway clearance. Elevating the head of the bed may assist the client but is not sufficient without additional interventions.
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