The nurse is caring for a client who needs suctioning for thick, tenacious secretions in the upper airway. Which nursing diagnosis should the nurse use for this client on the basis of the assess-ment data?
1. At risk for aspiration
2. Gas exchange, impaired
3. Total fluid volume deficit
4. Airway clearance, ineffective
4
4. Thick, tenacious secretions are difficult to remove from the upper airway, so inef-fective airway clearance is a suitable nursing diagnosis because the assessment data indicate the secretions are accumulating in the upper airway. Because the client can-not or does not cough out the secretions, the client must be suctioned to maintain the airway otherwise the secretions can accumulate until they occlude the airway.
1. Thick, tenacious secretions in the upper airway, generally, do not increase the risk of aspiration. Because the secretions are so thick, they remain in the nasal cavity.
2. Thick secretions in the upper airway do not affect gas exchange occurring in the alveoli of the lungs. If the secretions totally occlude the airway, then gas exchange can be affected.
3. Deficient fluid volume is a reasonable nursing diagnosis for this client because thinner secretions containing more water are easier to remove; however, insufficient data are presented to reach this conclusion.
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