You are writing a care plan for an 85-year-old patient who has community-acquired pneumonia and you note decreased breath sounds to bilateral lung bases on auscultation. What is the most appropriate nursing diagnosis for this patient?
A) Ineffective airway clearance related to tracheobronchial secretions
B) Pneumonia related to progression of disease process
C) Poor ventilation related to acute lung infection
D) Immobility related to fatigue
Ans: A
Feedback:
Nursing diagnoses are not medical diagnoses or treatments. The most appropriate nursing diagnosis for this patient is "ineffective airway clearance related to copious tracheobronchial secretions." "Pneumonia" and "poor ventilation" are not nursing diagnoses. Immobility is likely, but is less directly related to the patient's admitting medical diagnosis and the nurse's assessment finding.
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