Question

A patient is admitted with the diagnosis of bronchitis, congestive heart failure, & fever. The nurse's assessment finds a temperature of 101F, peripheral edema, & rhonchi. Which of the following is the best etiology to support the nursing diagnosis of ineffective airway clearance?

a. Allergic reaction to medication
b. Impaired gas exchange
c. Inflammation and constriction of the bronchial tree
d. Excessive fluid intake

Answer 1

The best etiology to support the nursing diagnosis of ineffective airway clearance is inflammation and constriction of the bronchial tree.

Step-by-step explanation:

The best etiology to support the nursing diagnosis of ineffective airway clearance in this case is inflammation and constriction of the bronchial tree (c).

Bronchitis is an inflammation of the bronchi, which causes redness, swelling, and a build-up of mucus in the air passages. This can lead to a narrowing of the airway, making it difficult for air to pass through and resulting in ineffective airway clearance. Rhonchi, which are rattling sounds heard during breathing, also indicate the presence of mucus and obstruction in the airway. Peripheral edema, or swelling in the extremities, is likely caused by congestive heart failure, which can contribute to the ineffective airway clearance.