A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority?
A) Acute Pain
B) Potential for Infection
C) Impaired Gas Exchange
D) Ineffective Airway Clearance
C
Feedback:
The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis Acute Pain is probable, gas exchange is a higher priority. Ineffective Airway Clearance is the least concern because the problem is with ventilation.
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