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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Negligence occurs when a person fails to perform their duties to the standard expected of a reasonable professional, leading to harm or potential harm. In this scenario, leaving a shift early without permission could be considered a breach of professional duty. Although the clients are stable, the action of leaving early without proper handoff could potentially create risks or gaps in care.
B. Battery involves the intentional and unauthorized physical contact with another person that causes harm or offense. This legal tort does not apply to the situation described because leaving a shift early does not involve physical contact or harm to the clients. Battery is more related to physical acts rather than administrative or procedural issues.
C. Libel refers to defamation through written statements that harm a person's reputation. This tort does not apply to the situation of leaving a shift early. Libel is concerned with false statements published in writing that damage someone's reputation, which is unrelated to the issue of leaving a shift early without notification.
D. Slander involves verbal defamation that harms a person's reputation. Like libel, slander is concerned with damaging someone’s reputation through spoken false statements. The scenario of leaving a shift early does not involve verbal defamation or reputational harm, so slander is not applicable here.

A. A semi-private room with a client who has pediculosis capitis B. A positive-pressure isolation room C. A private room D. A negative-pressure isolation room

Correct Answer is C

Explanation

A. This would not be appropriate as both scabies and pediculosis capitis are contagious skin infestations. Placing these clients together increases the risk of cross-contamination.
B. Positive-pressure isolation rooms are used for clients with compromised immune systems to protect them from pathogens. This is not necessary for a client with scabies.
C. A private room is the most appropriate choice for a client with scabies to prevent the spread of the infestation.
D. Negative-pressure isolation rooms are used for clients with airborne diseases to prevent the spread of pathogens. This is not necessary for a client with scabies.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is C

Explanation

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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.)