The client has a nursing diagnosis of Impaired gas exchange as a result of excess secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus on which of the following client indicators?

a. Ability to perform incentive spirometry
b. Lungs clearing bilaterally on auscultation
c. Complaint of chest pain
d. Respiratory rate


B

Feedback
A The client's ability to perform incentive spirometry does not determine whether the client's airways are clear. It is an intervention that may help achieve clear airways.
B Auscultating lung sounds is the best way to determine whether airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement.
C A complaint of chest pain would be a negative outcome and is not the focus for determining whether airways are free of secretions, as written in the outcome statement.
D Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine whether airways are free of secretions.

Nursing

You might also like to view...

A 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination

She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patient's lump is cancerous? A) Eversion of the right nipple and mobile mass B) A nonmobile mass with irregular edges C) A mobile mass that is soft and easily delineated D) Nonpalpable right axillary lymph nodes

Nursing

By which standard is the right of access to emergency services gauged?

1. That of a reasonable physician 2. That of a prudent and reasonable nurse 3. That of a prudent layperson 4. That of an ethical insurance provider

Nursing

Which two phases make up normal sleep?

a. Hypnagogic and hypnopompic b. Rapid eye movement (REM) and non REM c. Alpha and beta d. Delta and theta

Nursing

The nurse is providing care in a community clinic that serves members of vulnerable populations. The best definition of a vulnerable population is:

a. clients with chronic diseases such as AIDS or heart failure. b. women and children. c. people living in rural areas. d. clients who are unable to gain access to health care when needed.

Nursing