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. This is an appropriate delegation to an LPN. It involves data collection, which is within the scope of LPN practice. The RN retains responsibility for medication administration and reconciliation.
B. This is inappropriate delegation. A complete assessment requires critical thinking and clinical judgment, which are within the scope of RN practice.
C. While documentation is important, it's usually the responsibility of the RN to ensure accurate and complete charting, especially for initial assessments.
D. Drawing conclusions and developing a plan requires nursing judgment and is the responsibility of the RN.

A. Right person B. Right communication C. Right supervision D. Right circumstances

Correct Answer is C

Explanation

A. The "right person" refers to ensuring that the task is delegated to an individual who has the appropriate skills, knowledge, and training for the task. While important, this does not directly address the ongoing monitoring of task completion.
B. The "right communication" involves providing clear, concise instructions about the task, including what needs to be done, how it should be done, and any specific expectations. Although communication is essential for effective delegation, checking in throughout the shift pertains more to the oversight and monitoring of the task.
C. The "right supervision" involves providing appropriate oversight and monitoring of the tasks delegated. This includes checking on the progress and ensuring that the tasks are being completed as expected. When the nurse checks with assistive personnel throughout the shift to determine if tasks are being completed, they are demonstrating the "right supervision."
D. The "right circumstances" involves ensuring that the situation is appropriate for delegating the task, including the conditions and context in which the task is performed. This right addresses the appropriateness of the delegation based on the current environment and patient needs, but it does not specifically relate to monitoring or following up on task completion.

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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.)

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Explanation

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Correct Answer is C

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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.)