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 A
Explanation
A. A bureaucratic leader strictly enforces rules and procedures to maintain compliance and ensure consistency within the organization. This leadership style emphasizes adherence to established policies, regulations, and guidelines. Bureaucratic leaders often focus on following protocols and standard operating procedures, ensuring that every task is completed according to set rules.
B. A laissez-faire leader adopts a hands-off approach, allowing team members to make decisions and manage their own work with minimal interference. This style provides autonomy to team members and does not emphasize strict rule enforcement or close supervision.
C. A situational leader adapts their leadership style based on the needs of the team and the specific circumstances they face. This approach is flexible and responsive, adjusting leadership methods to the situation at hand. While situational leaders may enforce rules when necessary, their primary focus is on adapting their style to fit the context and the needs of the team rather than strictly enforcing rules.
D. A transformational leader focuses on inspiring and motivating team members to achieve their best and to embrace change and innovation. This style is characterized by a focus on vision, inspiration, and fostering a positive work environment.
Correct Answer is D
Explanation
A. While clinical judgment is essential in decision-making, it is based on experience and intuition. While valuable, it alone is not sufficient for evidence-based decision-making.
B. Critical thinking is a vital component of clinical decision-making, but it focuses on analyzing information and evaluating options. It's part of the process but doesn't encompass the entire evidence- based decision-making framework.
C. This is a visual tool used to organize information and identify relationships. It's a helpful aid in decision-making but not the core component.
D. This involves using critical thinking, knowledge, and experience to analyze patient data, consider options, and make decisions. It is the process of applying evidence to patient care and is therefore the most accurate answer.
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