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.
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