NCMA 312: MEDICAL SURGICAL 1

NAME: DIMAYUGA, BRYAN S.A.

SECTION: SECTION 2

1. Give the rationale for each of the following nursing interventions and selected activities for the
nursing care plan for ineffective airway clearance: (20 pts)
INTERVENTIONS RATIONALE
1. Encourage the client to take several deep ● Other than Promote Oxygenation, Performing Deep
breaths Breaths is a more efficient way for your body to
accomplish full gas exchange.
2. Encourage the client to take a deep breath, ● This is a correct practice for proper ways of coughing
hold for 2 seconds, and cough two or three times in and breathing, and pushing out the secretions and
succession. making it clear the airways for better breathing.

3. Encourage the use of incentive spirometry, as ● This may be recommended after surgery or when you
appropriate. have lung illness like pneumonia, it expands the lungs,
gives strength, keeps your lungs inflated, removes
mucus, and secretions from chest and lungs.
4. Promote systemic fluid hydration, as ● Fluids help for the secretions to easily pass through via
appropriate. minimized mucosal dryness and maximized ciliary
activity.
5. Monitor the rate, rhythm, depth, and effort ● Determining whether breathing is sufficient and
of respirations. allowing for the observation of alterations to
respiration.
6. Note chest movement, watching for ● Indicating a shift in respiration might help doctors
symmetry, use of accessory muscles, and determine whether a patient is having problems
supraclavicular and intercostal muscle retractions. breathing.

7. Auscultate lung sounds after treatments to ● To determine if aberrant lung sounds or accidental
note results. sounds of breathing are present.

8. Monitor the client’s respiratory secretions. ● To recognize abnormal secretion appearance that might
be caused by an infection, bronchitis, long-term
smoking, or another illness.
9. Monitor the client’s ability to cough ● A secretion-clearing procedure is coughing. Ineffective
effectively. coughing makes it harder to clear the airways and
prevents mucus from draining.
10. Monitor for increased restlessness, anxiety, and ● It might be the first indication of cerebral hypoxia. As a
air hunger. result, we must keep an eye on it.

1 | DIMAYUGA, BRYAN S.A.

 NCMA 312: MEDICAL SURGICAL 1

2. Match the following concepts with each other. Write the letter only. Use CAPITAL letters. (2
points each)
ANSWER COLUMN A COLUMN B
E 1. Tracheostomy A. Upper airway obstruction, upper airway bleeding, inability to
clear lower airway secretions, laryngeal or tracheal fracture, airway
burns, need for continuous ventilation, decreased LOC with
inability to protect the airway.

B 2. Oxygen Therapy B. Nasal cannula, face mask, non-rebreather, partial

non-rebreather, venture mask, face tent.

A 3. Assessments for C.Reduced oxygen in the blood characterized by a low PO2 or Sa02
the need to suction

C 4. Hypoxemia D. Percussions over congested areas can mechanically dislodge

tenacious secretions from the bronchial walls.

F 5. Incentive E.Surgical opening into the trachea with the creation of a stoma
Spirometry

G 6. Tracheostomy F. Improve pulmonary ventilation, counteract the effects of

precautions anesthesia/hypoventilation, loosen respiratory secretions, facilitate
respiratory gaseous exchange, and expand collapsed alveoli.

H 7. Indications for G. Keep duplicate tract tube with obturator at bedside, keep foreign
Tracheostomy objects such as aerosols and powders away from trach, provide
humidified air and 02, keep the stomata dry, good oral and nasal
hygiene, medical/ surgical asepsis.

D 8. Chest Percussion H. Restlessness, gurgling sounds during respiration, adventitious

breath sounds when the chest is auscultated, change in mental
status, skin color, rate and pattern of respiration, pulse rate, and
rhythm.

2 | DIMAYUGA, BRYAN S.A.