Question

question 10 of 10
the assessment of a client admitted with increased ascites related to cirrhosis reveals the following: pulse 86 beats per minute and weak, respirations 28 breaths per minute, blood pressure 130/88 mm hg, and pulse oximetry 90%. which nursing diagnosis should receive top priority?

• fatigue
• ineffective breathing pattern
• excess fluid volume
• imbalanced nutrition: less than body requirements

Explanation:

To determine the top - priority nursing diagnosis, we analyze the client's assessment data. The client has a respiratory rate of 28 breaths per minute (which is above the normal range) and a pulse oximetry of 90% (below the normal range of 95 - 100% for a healthy adult). An ineffective breathing pattern can lead to inadequate oxygenation and ventilation, which is a life - threatening situation. Fatigue is a more chronic or less immediately life - threatening issue. Excess fluid volume (related to ascites) is a concern but not as immediately life - threatening as impaired breathing. Imbalanced nutrition is also a long - term concern rather than an immediate threat to life. So, the most immediate and life - threatening problem here is the ineffective breathing pattern.

Answer:

B. Ineffective breathing pattern