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 ["9.6"]
Explanation
Step 1 is: Locate the section on the Penicillin G label that provides reconstitution instructions for intramuscular (IM) injection.
Step 2 is: Identify the desired dose of Penicillin G, which is 350,000 units.
Step 3 is: Examine the label to find the different dilution options and the resulting concentration (units/mL) for IM administration. The label provides the following reconstitution guidelines for IM injection:. Add 9.6 mL of sterile water for injection to yield 1,000,000 units/mL (Total volume: 10 mL). Add 4.6 mL of sterile water for injection to yield 2,000,000 units/mL (Total volume: 5 mL).
Step 4 is: Determine which dilution would be most appropriate for administering 350,000 units. Using the 1,000,000 units/mL concentration:. Volume to administer = Desired dose ÷ Concentration. Volume to administer = 350,000 units ÷ 1,000,000 units/mL = 0.35 mL. Using the 2,000,000 units/mL concentration:. Volume to administer = Desired dose ÷ Concentration. Volume to administer = 350,000 units ÷ 2,000,000 units/mL = 0.175 mL.
Step 5 is: Consider the practicalities of administering such small volumes. While both are technically correct, administering 0.35 mL is generally easier and more accurate than 0.175 mL with standard syringes. Therefore, diluting to yield 1,000,000 units/mL is the more appropriate choice. The question asks for the most appropriate diluent amount, which corresponds to this concentration. To achieve a concentration of 1,000,000 units/mL, 9.6 mL of diluent should be added.
Final Answer: The most appropriate diluent amount is 9.6 mL of sterile water for injection to yield a concentration of 1,000,000 units/mL, and then administer 0.35 mL.
Correct Answer is A
Explanation
Choice A rationale
Maslow's hierarchy of needs is a framework that prioritizes human needs in a hierarchical order, starting with physiological needs, followed by safety, love and belonging, esteem, and self-actualization. In the planning phase of nursing, this framework helps nurses to establish priorities of care by addressing the most basic and urgent needs first before moving to higher-level needs.
Choice B rationale
Piaget's cognitive developmental theory describes the stages of intellectual development in children and adolescents. While understanding cognitive development can inform nursing care, it is not the primary framework used for establishing priorities of care during the planning phase.
Choice C rationale
Erikson's stages of psychosocial development outline the social and emotional challenges individuals face across the lifespan. While relevant to understanding a client's psychosocial well-being, it is not the primary framework for prioritizing immediate nursing interventions in the planning phase.
Choice D rationale
Kohlberg's stages of moral development describe the progression of moral reasoning. While understanding a client's moral perspective can be relevant in certain situations, it is not the central framework used for establishing the priorities of physiological and safety needs in the nursing care plan. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.