The nurse assesses these symptoms in a client with bacterial pneumonia: chills, elevated temperature, tachypnea, productive cough of yellow sputum, shortness of breath, and fatigue. Based on the assessment data, what is the most appropriate nursing diagnosis (ND) for this client?

Question

Quizplus · Accepted Answer

Impaired gas exchange is a deficit in oxygenation and/or elimination of carbon dioxide at the alveolar-capillary membrane. Impaired gas exchange related to a bacterial infectious process as evidenced by shortness of breath and tachypnea is an appropriate ND for a client with pneumococcal pneumonia. (Option B) Impaired spontaneous ventilation is the inability to maintain independent ventilation to support life and requires mechanical ventilation. Based on this client's assessment data, it is not an appropriate ND. (Option C) This client is demonstrating an ineffective breathing pattern; however, this problem is secondary to impaired gas exchange. An increased respiratory rate is the body's attempt to compensate for hypoxia caused by consolidations and secretions preventing adequate gas exchange in the lungs. Impaired gas exchange is the primary problem that is causing the ineffective respirations and is the more appropriate ND for this client. (Option D) Risk for infection is the increased risk for invasion of microorganisms. However, this client has an actual, not potential infection, so this is not an appropriate ND. Educational objective: Impaired gas exchange related to a bacterial infectious process as evidenced by shortness of breath and tachypnea is an appropriate nursing diagnosis for a client with pneumonia.

The Nurse Assesses These Symptoms in a Client with Bacterial