A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct?
A) "needs nasal oxygen to improve breathing"
B) "cough related to ineffective airway clearance"
C) "ineffective airway clearance related to thick mucus"
D) "refuses to cough and expectorate thick mucus"

Question

Quizplus · Accepted Answer

The nursing diagnosis should be based on the patient's actual or potential health problems, and should be formulated with a problem, etiology, and symptoms. In this case, "ineffective airway clearance" is the problem, "related to thick mucus" is the etiology, and the symptom would be the patient's difficulty breathing or other respiratory-related symptoms. Option A is incorrect because it is not a nursing diagnosis, but rather an intervention. Option B is almost correct, but it is missing the etiology (i.e., related to thick mucus). Option D is incorrect because it is a behavior and not a diagnostic statement.

A Nurse Is Formulating a Nursing Diagnosis for a Client