问题
单项选择题
From an analysis of the data collected about the client who has had a gastric resection, the nurse formulates the nursing diagnosis Risk for ineffective airway clearance. Based on which of the following postoperative factors would the nurse make this diagnosis
A. Incisional pain.
B. Nausea.
C. Progressive ambulation.
D. Maintenance of a semi-Fowler’s position.
答案
参考答案：A
解析：Breathing and coughing cause pain in clients with high abdominal incisions. Chest excursion decreases, which decreases coughing and deep-breathing efforts. Shallow breathing leads to hypoventilation and atelectasis.