A patient is admitted with the diagnosis of bronchitis, congestive heart failure, and fever. The nurse's assessment finds a temperature of 101 ° F, peripheral edema, and rhonchi
Which of the following is the best etiology to support the nursing diagnosis of ineffective airway clearance?
a.
Peripheral edema
b.
Retained secretions
c.
Bronchitis
d.
Congestive heart failure
ANS: B
A
Peripheral edema is related to the accumulation of fluid in the feet and legs but has nothing to do with the airway.
B
The nursing diagnosis indicates that "something" may be blocking the airway. Respiratory secretions are the only choice that could block the airway.
C
Bronchitis is a medical diagnosis.
D
Congestive heart failure is a medical diagnosis.
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