A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is
a) Deficient fluid volume related to increased fluid needs
b) Ineffective airway clearance related to excess mucus production
c) Acute pain related to upper airway irritation
d) Deficient knowledge related to prevention of upper respiratory infections
Answer: b) Ineffective airway clearance related to excess mucus production
Explanation:
All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis. pg.540
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