A nurse is caring for a client with thick sputum who is having ...

[tuffie]

A nurse is caring for a client with thick sputum who is having difficulty bringing up mucus. Which nursing diagnosis would the nurse most likely identify?
 
  A) Ineffective Airway Clearance
  B) Acute Pain
  C) Risk for Injury
  D) Impaired Oral Mucous Membranes

Question 2

A nurse is assigned to care for a client with bronchial irritation. The client is prescribed diphenhydramine. Before administering the drug, which of the following would the nurse do?
 
  A) Document color and amount of any sputum present.
  B) Record the previous prescriptions.
  C) Take vital signs every 4 hours.
  D) Assess the client's cardiovascular status.

[lgoldst9]

Answer to Question 1

Ans: A
Feedback:
Thick sputum interferes with moving air effectively in and out of the respiratory tract. Therefore, the most likely nursing diagnosis would be Ineffective Airway Clearance. There is no evidence of pain. Risk for Injury would be appropriate if the client was experiencing sedation or drowsiness from the prescribed medication. Impaired Oral Mucous Membranes would be appropriate if the client was experiencing dry mouth from the medication.

Answer to Question 2

Ans: A
Feedback:
Before drug administration, the nurse should document the color and amount of any sputum present. The nurse need not record the previous prescriptions; however, the nurse should determine if any drugs the client uses would potentially interact with diphenhydramine. The nurse needs to take the client's vital signs, but not every 4 hours. The nurse needs to assess the respiratory status of the client before administering mucolytics and expectorants, but not before administering diphenhydramine HCl. Assessing the client's cardiovascular status is not necessary.

[tuffie]

TYSM

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Gracias!