A nurse is caring for a client with thick sputum who is having difficulty bringing up mucus. Which nursing diagnosis would the nurse most likely identify?
A) Ineffective Airway Clearance
B) Acute Pain
C) Risk for Injury
D) Impaired Oral Mucous Membranes
Ans: A
Feedback:
Thick sputum interferes with moving air effectively in and out of the respiratory tract. Therefore, the most likely nursing diagnosis would be Ineffective Airway Clearance. There is no evidence of pain. Risk for Injury would be appropriate if the client was experiencing sedation or drowsiness from the prescribed medication. Impaired Oral Mucous Membranes would be appropriate if the client was experiencing dry mouth from the medication.
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