Based on the following information, what would the nurse identify as t

Based on the following information, what would the nurse identify as the most appropriate nurs-ing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, and varia-ble respiratory rate.

1. Risk for injury
2. Excess fluid volume
3. Ineffective airway clearance
4. Impaired spontaneous ventilation

ANSWER

ANS: 3
The defining characteristics of abnormal breath sounds, dyspnea, an intermittent cough, and var-iable respiratory rate cue the nurse to the nursing diagnosis of ineffective airway clearance. Risk for injury does not support the diagnostic label of risk for injury. Excess fluid volume does not support the diagnostic label of excess fluid volume. There would be other defining characteristics such as edema, weight gain, and an elevated blood pressure. Impaired spontaneous ventilation does not most accurately describe impaired spontaneous ventilation. Other characteristics, such as apnea, would better support the diagnostic label of impaired spontaneous ventilation.