The nurse is caring for a client who had major abdominal surgery yesterday. Which assessment finding would indicate inadequate airway clearance that might be cleared with coughing and deep breathing?
1. Tachypnea with rales heard in the upper lobes and over the trachea
2. Bradypnea with wheezing heard throughout all lung fields
3. Tachypnea with wheezing heard throughout all lung fields
4. Tachypnea with rhonchi heard in the lower lobes
1
Rationale 1: The client with inadequate airway clearance would most likely be found tachypneic, with rales in the upper lobes and over the trachea indicating secretions are high enough in the airway to clear with coughing.
Rationale 2: Wheezing is heard with airway narrowing. It is unlikely that the client will have slow respirations.
Rationale 3: Wheezing is heard with airway narrowing.
Rationale 4: Rhonchi would be heard if the airway was narrowed from secretion collection in the smaller airways.
Global Rationale: The client with inadequate airway clearance would most likely be found tachypneic, with rales in the upper lobes and over the trachea indicating secretions are high enough in the airway to clear with coughing. Wheezing is heard with airway narrowing, whereas rhonchi would be heard if the airway was narrowed from secretion collection in the smaller airways. It is unlikely that the client will have slow respirations.
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