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 D
Explanation
A. While a quiet environment is generally desirable for patients, a client in a manic phase often experiences increased energy and agitation. A quiet room might not adequately address their need for constant monitoring.
B. Seclusion should be used as a last resort and only in cases where the client poses an immediate danger to themselves or others. It is not appropriate for routine management of mania.
C. While it might seem helpful to pair patients with similar conditions, a manic patient can be disruptive to roommates, affecting their well-being and potentially escalating their own symptoms.
D. This option is the most appropriate. A private room provides necessary privacy and space, while proximity to the nursing station allows for close observation and rapid intervention if needed.
Correct Answer is B
Explanation
A. Advocacy involves protecting the client's rights and interests. While the nurse is acting in the client's best interest by assessing and reporting the error, the primary action here is taking responsibility.
B. Accountability is taking responsibility for one's actions and their consequences. By admitting the medication error, assessing the client, notifying the provider, and completing an incident report, the nurse is demonstrating accountability for their actions.
C. Confidence is believing in one's abilities. While confidence is important in nursing, it is not the primary characteristic displayed in this scenario.
D. Fairness involves treating everyone equally. This is not directly related to the nurse's actions in this case.
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