Question

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance?

A) Absence of adventitious sounds.
B) Productive cough.
C) Clear breath sounds.
D) Tachypnea.

Answer 1

The finding of tachypnea best supports the nursing diagnosis of ineffective airway clearance. This, along with a productive cough and crackling sounds in the lungs, suggests an obstruction in the airway, potentially from conditions like pneumonia or bronchitis.

Step-by-step explanation:

The nursing diagnosis of ineffective airway clearance is best supported by the finding of tachypnea. Tachypnea, or rapid breathing, is often a response to lower oxygen levels in the blood or difficulty in clearing the airway, such as mucus blockage or lung diseases. The presence of productive cough noting the greenish color of the mucus, and abnormal sounds such as crackling in the lungs detected during a respiratory assessment can also indicate ineffective airway clearance, which are frequently seen in conditions like pneumonia and bronchitis. These conditions lead to an accumulation of mucus that obstructs the airways, presenting a challenge in clearing the airways effectively.

Diagnostic tools such as spirometry and the use of a nebulizer can help assess lung function and contribute to the diagnosis of restrictive lung diseases. In patients with respiratory distress, such as the case of an immunocompromised patient described in the case studies, a range of symptoms including productive wet cough, dyspnea, and reduced blood-oxygen saturation indicate that the airways may not be clearing effectively.