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Home Q & A Board Biology-Related Homework Help Medicine Nursing and Clinical
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Anastasia26 Anastasia26
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6 years ago
Assessment of a client with difficulty breathing reveals that he has thick, tenacious secretions in his trachea and bronchi and excessive sputum with coughing. His respiratory rate is slightly increased.
 
  When developing this client's plan of care, which nursing diagnostic label would be most appropriate?
  A) Risk for activity intolerance
  B) Disturbed sleep pattern
  C) Ineffective airway clearance
  D) Impaired spontaneous ventilation
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#1
6 years ago
Ans: C
Feedback:
Based on the assessment, the nurse should identify specific cues, such as the thick secretions, excessive sputum, and coughing, which would indicate a problem with a clear airway. Although the client may be experiencing problems with his activity level or a disruption in his sleep from coughing, there is no indication that either of these is occurring. The client's respiratory rate is increased; however, he is breathing independently.
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