A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?

Question

Quizplus · Accepted Answer

Postoperative clients are at risk for atelectasis and possibly for pneumonia following surgery as a result of retained secretions. Effective coughing is essential to prevent these complications. The nurse can promote many client actions that will facilitate effective coughing. These include splinting the incision while coughing, changing position every 1-2 hours, ambulating early, using an incentive spirometer, and hydrating adequately to thin the secretions. However, all of these interventions are less effective if the client is in pain. The nurse should instruct the client to request pain medication before the pain becomes intense. Pain relief should be addressed prior to implementing coughing exercises and ambulation. (Options B, C, and D) These are appropriate interventions but will be more effective if pain is managed first. Educational objective: The nurse should ensure that the postoperative client has effective pain relief before performing coughing exercises.

A Nursing Diagnosis of "Ineffective Airway Clearance Related to Pain