A nurse is assessing a client who is postoperative.. Which of the following findings should the nurse identify as objective data?
(Select All that Apply.)
The client's current blood pressure is below their preoperative reading.
The client's right calf is swollen and warm to the touch.
The client is reporting nausea.
The client states they are experiencing "extreme pain".
The client's urine output has been 150 mL over the past 3 hr.
Correct Answer : A,B,E
A. Blood pressure is a measurable physiological parameter that can be accurately recorded by the nurse using a sphygmomanometer. It provides concrete evidence of the client’s current condition compared to their preoperative baseline.
B. The swelling and warmth of the calf are observable and measurable physical signs that the nurse can assess through physical examination. These findings can be documented and evaluated independently of the client's personal feelings or reports.
C. Nausea is a symptom experienced and reported by the client. It cannot be directly measured or observed by the nurse but rather is based on the client's personal sensations and experiences.
D. Pain is a personal experience and is reported by the client. The description of pain, including its intensity and quality, is based on the client's own perception and cannot be directly measured by the nurse.
E. Urine output is a quantifiable measurement that can be recorded and assessed by the nurse. It
provides concrete information about the client’s fluid balance and renal function over a specific period.
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Related Questions
Correct Answer is B
Explanation
A. Advocacy involves supporting and defending a patient's interests. While evaluating pain medication is important, it doesn't directly demonstrate advocacy.
B. By checking the effectiveness of pain medication, the nurse is fulfilling their responsibility to provide optimal care and manage patient pain.
C. Confidence is important for nurses, but it's not directly demonstrated in this specific action.
D. Fairness is a broader concept related to treating all patients equitably. Evaluating pain medication is a standard of care for all patients experiencing pain, regardless of their background or circumstances.
Correct Answer is A
Explanation
A. This client should be assessed first. Chest pain is a serious symptom that could indicate a cardiac event. The new onset of indigestion, even if unrelated, warrants immediate assessment to rule out any cardiac complications.
B. While hypoglycemia is a serious condition, the client's blood glucose is now within a normal range after treatment. This client can be assessed after the client with chest pain.
C. Pneumonia is a serious condition, but the client's temperature has been managed, and there is no indication of immediate instability. This client can be assessed after the first two.
D. While the IV catheter needs to be replaced, this is not an emergent situation. The client can receive the famotidine orally until the IV is replaced.
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