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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
A. While burnout can certainly impact communication, it's more of a consequence of poor communication and teamwork rather than a direct barrier to it. Addressing communication issues can help mitigate burnout.
B. Privacy laws are essential to protect patient information but are not inherently barriers to communication. Effective communication can occur while maintaining patient privacy.
C. This is a direct barrier to interprofessional communication. If team members don't understand each other's responsibilities, it can lead to confusion, duplication of efforts, and a breakdown in communication.
D. While understanding scope of practice is crucial for effective collaboration, it's not a barrier to communication itself. In fact, clear role definitions can enhance communication.
Correct Answer is D
Explanation
A. Teaching a client how to use an incentive spirometer involves providing detailed instruction and education about the device and its use. This task requires clinical knowledge and the ability to assess and address the client’s understanding, which is beyond the scope of an AP.
B. Irrigating and performing a dressing change on a pressure injury wound is a clinical task that requires specific training and skill, including knowledge of wound care, infection control, and assessment of wound healing. This is typically performed by an RN or another licensed healthcare professional. This task involves clinical judgment and assessment, which are beyond the training of an AP.
C. Administering medication, including PRN (as needed) pain medication, involves assessing the client’s condition, verifying the medication order, and monitoring for effects and side effects. This task requires a licensed nurse who can perform these assessments and make clinical decisions.
D. Obtaining a daily weight is a task that is within the scope of practice for an AP. Weighing a client does not require clinical judgment or complex decision-making and is typically considered a routine task that can be safely delegated to an AP. This task involves measuring and recording the client’s weight, which is an objective and straightforward task.
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