The nurse is caring for a client who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions. Which of the following actions should the nurse implement initially?
A)Suction the client's oral and pharyngeal airway.
B)Administer oxygen at 7-9 L/minute with a face mask.
C)Place the hands just below the xiphoid process and push upward when the client coughs.
D)Encourage the client to use an incentive spirometer every 2 hours during the day.

Question

Quizplus · Accepted Answer

Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. The nurse places the heels of both hands just below the client's xiphoid process and exerts firm upward pressure to the area, timed with the client's efforts to cough. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the client's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the client is unable to expel secretions by coughing but should not be the nurse's first action.

The Nurse Is Caring for a Client Who Had a C8