The nurse is caring for a group of patients on a medical surgical unit. Which of the following patients is at most risk for developing gout?

Choice A rationale:
Coughing and deep breathing: These techniques directly promote airway clearance by mobilizing and expelling secretions from the lungs. They are essential for clients with pneumonia, as the buildup of secretions can obstruct the airways and impair gas exchange.
Hydration maintenance: Adequate hydration helps to thin secretions, making them easier to cough up and clear from the lungs. It also helps to prevent dehydration, which can worsen respiratory symptoms.

Choice B rationale:
Keeping the head of the bed elevated: This can help to improve breathing by decreasing the work of breathing and promoting lung expansion. However, it is not the most effective intervention for directly clearing secretions from the lungs.

Choice C rationale:
Preparation for insertion of a tracheostomy tube: This is a more invasive intervention that may be necessary in severe cases of airway obstruction. However, it is not the priority intervention for a client with ineffective airway clearance related to pneumonia.

Choice D rationale:
Providing supplemental oxygen: This can help to improve oxygenation in clients with pneumonia. However, it does not directly address the problem of ineffective airway clearance.

Choice A rationale:
Coughing and deep breathing are essential for mobilizing and removing secretions from the airways, which is crucial for improving airway clearance in patients with pneumonia. These techniques help to loosen mucus and bring it up from the lungs, allowing it to be expelled through coughing.
Hydration maintenance is also critical because it helps to thin secretions, making them easier to cough up. Adequate hydration helps to keep mucus moist and less sticky, which promotes easier expectoration.
Choice B rationale:
Keeping the head of the bed elevated can help to improve oxygenation and reduce the work of breathing, but it does not directly address the issue of airway clearance. It may be a helpful adjunct intervention, but it's not the priority for this specific nursing diagnosis.
Choice C rationale:
Preparation for insertion of a tracheostomy tube is a more invasive intervention that may be necessary in severe cases of airway obstruction, but it is not the first-line intervention for ineffective airway clearance related to pneumonia. It would be considered if other measures fail to maintain adequate ventilation.

Choice D rationale:
Providing supplemental oxygen can help to improve oxygenation in patients with pneumonia, but it does not directly address the issue of airway clearance. It's important to support oxygenation, but it's not the primary intervention to clear secretions.