Question

A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan?

1)Determine airway adequacy hourly and as needed.

2)Administer oxygen as needed.

3)Monitor arterial blood gas values.

4)Place the client in a high Fowler's position.

Answer 1

The first step in the care plan for a client with an ineffective breathing pattern should be to verify that the airway is clear and adequate on an hourly basis and as required.

Step-by-step explanation:

The first nursing intervention that should be listed on the care plan for a client with an ineffective breathing pattern related to the inability to maintain adequate rate and depth of respirations would be to determine airway adequacy hourly and as needed. Ensuring that the patient's airway is clear and unobstructed is the most crucial initial step, as it allows for adequate oxygen intake and carbon dioxide elimination, which is vital for the proper functioning of all other body systems. Once the airway is determined to be adequate, the other interventions can be implemented as appropriate, including administering oxygen, monitoring arterial blood gas values, and placing the client in a high Fowler's position to facilitate easier breathing.