The client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. The client is receiving humidified oxygen. A priority nursing diagnosis is:
a) impaired gas exchange related to ventilation-perfusion inequality
b) ineffective breathing pattern related to inflammatory effects of surgery
c) ineffective airway clearance related to excess mucus production
d) anxiety related to the effects of surgery and loss of voice
Answer: c) ineffective airway clearance related to excess mucus production
Explanation:
All may be appropriate nursing diagnoses for this client. The nurse would follow Maslow's hierarchy of needs and ABCs (airway, breathing, circulation) to determine highest priority. Ineffective airway clearance is the nursing diagnosis of highest priority. pg.551
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