A patient is admitted to a respiratory unit with a diagnosis of left lower lobe pneumonia. The nursing assessment reveals the patient to be febrile and experiencing a weak, congested-sounding cough
The patient has moist crackles throughout the lung fields. Based on the data provided, which nursing diagnosis is most appropriate?
a. Anxiety
b. Impaired Gas Exchange
c. Ineffective Breathing Pattern
d. Ineffective Airway Clearance
ANS: D
Data point to excessive secretions that the patient is not completely coughing up, so Ineffective Airway Clearance is the best choice. A. B. C. Although they may be concerns with pneumonia, there is no evidence of anxiety, impaired gas exchange, or ineffective breathing pattern.
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