He nurse is planning care for a client with respiratory acidosis who is experiencing ineffective airway clearance. What interventions should the nurse include in this client's plan of care? (Select all that apply.)
1. Provide chest physiotherapy
2. Coach to breathe into a paper bag
3. Encourage frequent position changes
4. Instruct in the use of pursed lip breathing
5. Suggest increasing oral fluids to 3 L per day
Answer: 1, 3, 4, 5
1. Chest physiotherapy through percussion, vibration, and postural drainage helps loosen respiratory secretions so they can be coughed out of airways.
2. Having the patient breathe into a paper bag is effective for an ineffective breathing pattern.
3. Frequent position changes promote airway clearance and lung expansion.
4. Pursed-lip breathing helps maintain open airways throughout exhalation, promoting carbon dioxide elimination.
5. Fluid intake of up to 3,000 mL/day helps liquefy secretions and hydrate respiratory mucous membranes, promoting airway clearance.
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