The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:
oxygen will be continued
the patient's coughing frequency will increase
cyanosis may be present
within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea
The Correct Answer is D
A. Oxygen will be continued: Continuing oxygen therapy is an intervention, not a measurable outcome.
B. The patient's coughing frequency will increase: While coughing can help clear secretions, increased coughing does not necessarily indicate improved airway clearance.
C. Cyanosis may be present: Cyanosis is a sign of worsening oxygenation, not an improved outcome.
D. Within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea: A desired outcome should be specific, measurable, and indicate improvement. The resolution of dyspnea demonstrates effective airway clearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Assistive personnel reports the patient walks with a limp: This is secondhand information (reported by UAP), not directly observed by the nurse.
B. Patient reports pain level as 3 on a scale of 1 to 10: Pain is subjective data because it is based on the patient's self-report.
C. Heart rate 72 beats per minute: Heart rate is measured by the nurse, making it objective data.
D. Respiratory rate 22 per minute with even unlabored respirations: The nurse directly observes and measures respiratory rate, making it objective data.
E. Coughed up 5 mL yellow sputum: The nurse can observe and quantify the sputum (color and volume), making it objective data.
F. Headache in frontal area: A headache is subjective data because only the patient can describe it.
Correct Answer is C
Explanation
A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.
B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.
C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.
D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.
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