The nurse would write which of the following nursing diagnoses for a client with respiratory disease to avoid documenting a legally inadvisable statement?
1. Risk for ineffective airway clearance related to refusal to cough and deep breathe
2. Risk for ineffective airway clearance related to laziness with respiratory exercises
3. Risk for ineffective airway clearance related to shallow breathing and weak cough
4. Risk for ineffective airway clearance related to not being given an incentive spirometer
Question 2
A client who feels the urge to void after surgery is reluctant to get out of bed and walk to the bathroom with the nurse because of incisional pain. Which of the following is the most appropriate nursing diagnosis for this client?
1. Acute pain related to verbal complaints of incisional discomfort
2. Ineffective breathing pattern related to incisional discomfort
3. Urinary retention related to reluctance to ambulate to bathroom
4. Risk for urinary retention related to reluctance to ambulate to bathroom
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
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Model of a nursing clinical decision support system
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