The nurse is caring for a patient with the nursing diagnosis of ineffective airway clearance related to narrowed airways and thick sputum.
Which is an appropriate expected outcome for this patient?
The patient's respiratory rate and pulse will remain within normal limits.
The patient's airway will remain clear throughout the night.
The patient will be resting comfortably by the morning.
The patient will not experience any feelings of shortness of breath or anxiety.
The Correct Answer is B
Choice A rationale
Maintaining a normal respiratory rate (typically 12-20 breaths per minute for adults) and pulse rate (typically 60-100 beats per minute for adults) are general indicators of stable physiological function but do not directly confirm airway clearance. While improved airway clearance can contribute to these stable vital signs, other factors can also influence them.
Choice B rationale
A clear airway directly addresses the nursing diagnosis of ineffective airway clearance. If the patient's airway remains unobstructed, thick sputum can be expectorated or managed, and narrowed airways will not impede airflow. This outcome specifically targets the problem identified in the nursing diagnosis.
Choice C rationale
Resting comfortably by the morning is a desirable outcome reflecting overall well-being, but it is not a direct measure of airway clearance. While improved breathing can contribute to comfort, other factors like pain or anxiety can also affect rest.
Choice D rationale
Absence of shortness of breath (dyspnea) and anxiety suggests improved respiratory function, but it doesn't definitively confirm the airway is clear of thick sputum or that narrowed airways are no longer a problem. The patient could still have airway issues without experiencing these symptoms consistently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Sharing information only with family members violates confidentiality unless the patient has provided explicit consent. The Health Insurance Portability and Accountability Act (HIPAA) protects patient health information from unauthorized disclosure, even to family, without patient permission.
Choice B rationale
Adherence to confidentiality principles mandates that healthcare professionals access patient medical records only when there is a legitimate clinical reason related to the provision of care for that specific patient. Accessing records out of curiosity or without a direct care responsibility is a breach of confidentiality.
Choice C rationale
Providing information only to another nurse is too restrictive. Confidentiality allows for the sharing of necessary patient information with all members of the healthcare team directly involved in the patient's care, not just nurses.
Choice D rationale
Providing information only to an attorney is incorrect. While patient records may be disclosed to attorneys in specific legal situations with proper authorization (e.g., subpoena, patient consent), healthcare professionals can also share information with other authorized individuals involved in the patient's care.
Correct Answer is C
Explanation
Choice A rationale
Providing additional written instructions is a helpful teaching strategy but does not directly demonstrate the patient's ability to self-administer the injection correctly. It addresses the teaching method, not the outcome of the teaching.
Choice B rationale
The patient denying concerns does not necessarily indicate successful learning. The patient might have unexpressed concerns or may not fully understand the procedure despite verbalizing otherwise. This statement reflects the patient's verbalization, not their demonstrated skill.
Choice C rationale
The patient correctly self-administering their next scheduled dose of insulin is the most direct and reliable evidence that the teaching was successful. It demonstrates that the patient has acquired the necessary knowledge and skills to perform the injection safely and accurately in a real-life situation.
Choice D rationale
Identifying the steps and equipment used indicates that the patient has some understanding of the procedure. However, it does not guarantee that they can perform the injection correctly. Practical demonstration is required to confirm successful learning of a psychomotor skill.
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