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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Checking the display on the PCA pump is the first action the nurse should take. This ensures that the pump is functioning correctly and delivering the prescribed dose of medication. It helps identify any technical issues that may be affecting pain control.
B: Obtaining an order for another pain medication for breakthrough pain is important if the current regimen is insufficient. However, this should follow the initial assessment of the PCA pump’s functionality.
C: Administering a bolus of medication may be necessary if the client is experiencing severe pain, but it should be done after confirming that the PCA pump is working correctly.
D: Encouraging the client to administer a demand dose is appropriate if the PCA pump is functioning correctly. However, the nurse should first verify that the pump is delivering the medication as prescribed.
Correct Answer is B
Explanation
A: Drinking cranberry juice each day can help prevent UTIs. Cranberry juice contains compounds that may prevent bacteria from adhering to the urinary tract walls, reducing the risk of infection.
B: Wiping the perineal area from back to front after urination is incorrect and increases the risk of introducing bacteria from the anal area to the urethra, leading to UTIs. The correct method is to wipe from front to back to minimize this risk.
C: Emptying the bladder regularly and completely is an important measure to prevent UTIs. It helps flush out bacteria from the urinary tract and reduces the risk of infection.
D: Drinking 8 cups of liquid each day is recommended to maintain adequate hydration and promote regular urination, which helps prevent UTIs by flushing out bacteria.
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