Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
a. Weak, nonproductive cough effort
b. Large amounts of greenish sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85%
ANS: A
The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
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