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 A
Explanation
Choice A rationale
The nursing process is a systematic, cyclical method used by nurses to identify and address patient health needs. It involves assessment, diagnosis, planning, implementation, and evaluation, providing a structured approach to problem-solving and the delivery of individualized care.
Choice B rationale
Standardized protocols offer guidelines for specific conditions but do not encompass the holistic and individualized nature of the entire nursing process. The nursing process allows for adaptation and critical thinking beyond pre-established routines to meet unique patient needs.
Choice C rationale
A legal document defining the scope of practice outlines what nurses are legally allowed to do. While the nursing process guides nursing actions, it is a framework for care delivery rather than a legal definition of professional boundaries.
Choice D rationale
While communication is integral to healthcare, the nursing process is more than just a communication tool. It is a comprehensive framework that guides all aspects of nursing care, from initial assessment to the evaluation of outcomes, involving critical thinking and clinical judgment.
Correct Answer is B
Explanation
Answer and explanation
The correct answer is Choice B.
Choice A rationale
Speculating about the cause of the fall ("probably urinated on the floor") is unprofessional and lacks factual basis. Charting should be objective and based on observed facts, not assumptions.
Choice B rationale
Documenting objective observations, such as finding the patient on the floor with the urinal nearby, provides a factual account of the incident without making assumptions or assigning blame. This allows for a more accurate analysis of potential contributing factors.
Choice C rationale
Commenting on the nurse assistant's work habits ("always took her time") is subjective, irrelevant to the fall incident itself, and unprofessional. Charting should focus on the patient and the event.
Choice D rationale
Describing the patient as "grouchy and inappropriate" is judgmental, subjective, and does not contribute to an understanding of the fall. Such personal opinions are inappropriate for medical documentation.
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