A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?

Petechiae

Blood pressure

Nausea

Cyanosis

Answer and Explanation

The Correct Answer is C

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.

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Correct Answer is C

Explanation

A: Calling the prescribing physician is important, but the immediate action should be to withhold the medication to prevent further elevation of potassium levels.

B: Calling the lab to verify the results can be done, but the immediate action should be to withhold the medication.

C: Omitting the KCL dose and documenting it is the correct action. The client’s potassium level is already elevated, and administering additional potassium could be harmful.

D: Giving the ordered KCL as prescribed is not appropriate because the client’s potassium level is already above the normal range.

A. Nasal cannula B. Simple face mask C. Aerosol mask D. Face tent

Correct Answer is B

Explanation

A: A nasal cannula delivers a lower concentration of oxygen, typically between 24-44% FIO2, and is used at flow rates of 1-6 L/min. It is not suitable for delivering 40-60% FIO2.

B: A simple face mask can deliver 40-60% FIO2 at flow rates of 5-8 L/min. It covers the nose and mouth, providing a higher concentration of oxygen compared to a nasal cannula.

C: An aerosol mask is used for delivering humidified oxygen or medications via nebulization. It can deliver varying concentrations of oxygen but is not specifically designed for 40-60% FIO2 at 5-8 L/min.

D: A face tent is used for patients who cannot tolerate a mask, such as those with facial trauma or claustrophobia. It provides humidified oxygen but does not deliver a precise FIO2 concentration.

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A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client’s most recent laboratory results and finds the client’s potassium level is 5.2 mEq/L. (Normal 3.5-5.0 mEq/L) Which action should the nurse take?

Correct Answer is C

Explanation

Which oxygen delivery device can deliver 40-60% FIO2 and is from 5-8 L/min?

Correct Answer is B

Explanation

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