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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The Joint Commission (TJC) is indeed known for providing accreditation to healthcare facilities. Accreditation by TJC is a mark of quality and signifies that a facility meets certain performance standards and complies with healthcare regulations. This accreditation process involves evaluating the quality and safety of care provided by the facility.
B. TJC does not monitor insurance claims. Instead, it focuses on accrediting and certifying healthcare organizations based on quality and safety standards. Monitoring insurance claims is typically the role of insurance companies or specific regulatory bodies related to insurance and billing practices, not TJC.
C. TJC does not provide licensure for healthcare providers. Licensure of healthcare professionals, such as nurses and physicians, is handled by state licensing boards or professional regulatory bodies, not by TJC. TJC’s role is primarily focused on accrediting healthcare facilities rather than licensing individuals.
D. The Joint Commission is a non-profit organization. It is dedicated to improving healthcare quality and safety through accreditation and certification. As a non-profit entity, TJC reinvests its resources into its mission to enhance the standards of care rather than focusing on generating profit.
Correct Answer is A
Explanation
A. Administering incompatible blood products is a significant medical error that can result in severe patient harm, including hemolytic transfusion reactions, which can be life-threatening. This type of incident qualifies as a sentinel event because it involves serious injury or death and necessitates immediate investigation and corrective actions to prevent recurrence.
B. While administering medications late is a medication error and can affect patient outcomes, it does not typically qualify as a sentinel event unless it results in serious harm or death. Sentinel events are generally those with more severe consequences or potential for significant harm.
C. Documenting vital signs at the wrong time is a documentation error and could potentially lead to issues in patient care. However, it is not classified as a sentinel event unless it results in significant harm or jeopardizes the patient's safety.
D. Administering a prescribed sedative for insomnia, when done according to a valid prescription and proper protocols, is a routine medical intervention and does not typically constitute a sentinel event. Sentinel events involve unexpected and serious outcomes rather than standard clinical procedures when performed correctly.
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