The client has a nursing diagnosis of impaired gas exchange as a resul

The client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus upon the client’s:

1. Respiratory rate
2. Complaint of chest pain
3. Lungs clear bilaterally on auscultation
4. Ability to perform incentive spirometry

ANSWER

ANS: 3
Auscultating lung sounds is the best way to determine if airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement. Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine if airways are free of secretions. A complaint of chest pain would be a negative outcome, and it is not the focus for determining whether airways are free of secretions as written in the outcome statement. Having the ability to perform incentive spirometry does not determine whether the airways are clear or not. It is an in-tervention that may help achieve clear airways.