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. Negligence involves failing to provide care that a reasonably prudent person would, resulting in harm. Leaving a computer terminal unattended, while not ideal, doesn't necessarily rise to the level of negligence unless it leads to a specific harm.
B. This is the most accurate choice. Leaving a computer terminal unattended with login credentials accessible to others is a breach of confidentiality and security protocols, which are fundamental aspects of professional nursing practice.
C. Malpractice is professional negligence. While leaving a computer unattended could potentially lead to a breach of patient privacy, it doesn't inherently constitute malpractice unless it results in harm to a patient.
D. Defamation involves making false statements that harm someone's reputation. Leaving a computer unattended is not related to defamation.
Correct Answer is D
Explanation
A. This is a professional and important action. Ensuring that a client is competent to consent means that the nurse is verifying that the client understands the nature, purpose, risks, and benefits of the procedure. Competence to consent is a legal and ethical requirement, and it is part of the nurse’s role to support and facilitate the informed consent process.
B. This is also a professional and necessary action. It involves checking that the client’s consent is given freely, without coercion or undue pressure. This step ensures that the consent is valid and ethical. It is part of the nurse's responsibility to ensure that the consent process respects the client's autonomy.
C. The nurse as a witness is there to observe that the consent is signed by the client and that the client understands what they are consenting to. However, the nurse should not be the one explaining the procedure or the risks involved unless they are specifically trained and authorized to do so.
D. This is generally not considered professional behavior for a nurse unless they have specific training and authorization to provide detailed information about surgical procedures. Typically, detailed explanations of the procedure are provided by the surgeon or a qualified healthcare provider.
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