Question

A patient is having difficulty coughing up secretions, has coarse wheezes (rhonchi) in the lungs, respiratory rate of 28, and dyspnea. The nurse recognizes these as symptoms of which nursing diagnosis?

a) Ineffective Breathing Pattern
b) Ineffective Airway Clearance
c) Impaired Gas Exchange
d) Impaired Deep Breathing

Answer 1

The patient's symptoms suggest the nursing diagnosis of Ineffective Airway Clearance, characterized by the inability to clear secretions from the respiratory tract.

Step-by-step explanation:

The symptoms described by a student—difficulty coughing up secretions, coarse wheezes (rhonchi) in the lungs, a respiratory rate of 28, and dyspnea—are characteristic of the nursing diagnosis of Ineffective Airway Clearance. This condition is indicative of an inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway, leading to altered breathing patterns and gas exchange. The use of spirometry can help in assessing the airway functionality by determining the rate at which air can be inhaled or exhaled, thus, providing support for this diagnosis. The signs are not indicative of only an altered breathing pattern or gas exchange issue, which could suggest other diagnoses such as Ineffective Breathing Pattern or Impaired Gas Exchange. Instead, they specifically point to an issue with clearing the airways, which is central to the diagnosis of Ineffective Airway Clearance.