A patient is admitted with the diagnosis of bronchitis,congestive heart failure,and fever.The nurse's assessment finds a temperature of 101° F,peripheral edema,and rhonchi.Which of the following is the best etiology to support the nursing diagnosis of ineffective airway clearance?
A) Peripheral edema
B) Retained secretions
C) Bronchitis
D) Congestive heart failure

Question

Quizplus · Accepted Answer

Retained secretions are a common cause of ineffective airway clearance and can occur in individuals with bronchitis and congestive heart failure. The presence of rhonchi also supports this etiology as it suggests the airways are partially blocked by mucus or secretions. Peripheral edema and congestive heart failure may contribute to oxygenation and circulation problems, but are not directly related to ineffective airway clearance. Bronchitis is the underlying condition causing inflammation and excess mucus production, but again it is not as directly related to the nursing diagnosis of ineffective airway clearance as retained secretions.

A Patient Is Admitted with the Diagnosis of Bronchitis,congestive Heart