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. This aligns with the "D" in IDEAL, which is to develop a discharge plan. The client's goals should be a central part of this plan.
B. While the discharge process is important, it's more about the steps involved in the discharge rather than a key area to discuss with the client.
C. While family input is valuable, the focus should be on the client's needs and goals.
D. Test results are important information for the client, but they are not one of the five key areas of the IDEAL toolkit.
Correct Answer is ["A","B","E"]
Explanation
A. This task can be delegated to AP as it involves physical assistance and does not require nursing judgment.
B. Feeding a client who has regained swallowing ability can be delegated to AP. However, the nurse should assess the client's ability to swallow safely before delegation.
C. This task requires patient education and assessment, which are within the scope of nursing practice and cannot be delegated.
D. Patient education requires nursing judgment and cannot be delegated to AP.
E. Bathing a client is a routine task that can be delegated to AP, as long as the AP has received appropriate training and the client's condition is stable.
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