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How does the nurse recognize ineffective airway clearance?
Asked on Jan 21, 2026
Answer
Ineffective airway clearance is identified by the nurse through specific assessment findings that indicate the patient's inability to clear secretions or obstructions from the respiratory tract. This can involve auscultation, observation, and patient-reported symptoms.
Example Concept: Ineffective airway clearance is characterized by abnormal breath sounds such as wheezing, crackles, or diminished breath sounds, use of accessory muscles for breathing, coughing with or without sputum production, and changes in respiratory rate or pattern. These findings suggest that the patient is unable to effectively clear airway secretions, which can lead to impaired gas exchange and respiratory distress.
Additional Comment:
- Assess for signs of hypoxia, such as cyanosis or altered mental status, which may accompany ineffective airway clearance.
- Use the ABCs (Airway, Breathing, Circulation) framework to prioritize interventions for airway management.
- Encourage coughing and deep breathing exercises to help mobilize secretions.
- Consider suctioning if the patient is unable to clear secretions independently.
- Document findings and interventions in the patient's medical record for continuity of care.
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