Question

WHAT WOULD BE YOUR PRIMARY CHOICE OF AN UNDERLYING DIAGNOSIS FOR MR. JOHNSON, AND WHY

Answer 1

Pulse rate of 110.
Tachycardia is consistent with an infectious process. In addition, Mr. Johnson's fever and rapid respiratory rate are also vital sign findings that indicate a problem, such as an infection pneumonia.

- Auscultate breath sounds.
This is the highest priority because Mr. Johnson is clearly exhibiting respiratory distress.

- Priority Nursing diagnosis:

Ineffective airway clearance
There are adventitious breath sounds present, tachypnea, changes in depth of respirations, fever, and cough, which support this as a priority diagnosis. Additional priority diagnoses are impaired gas exchange and ineffective breathing patterns. Impaired gas exchange is reflected in Mr. Johnson's hypercapnia and hypoxia. The diagnosis of ineffective breathing pattern is supported by his tachypnea, use of accessory muscles, and changes in the depth of respiration.