A nurse is conducting a patient’s history and physical examination. Which information should the nurse consider as subjective data?
Petechiae
Nausea
Cyanosis
Fever
The Correct Answer is B
Choice A rationale
Petechiae, or small red or purple spots on the skin caused by minor bleeding from broken capillary blood vessels, are an objective finding. They can be seen and evaluated by the nurse during a physical examination.
Choice B rationale
Nausea is a subjective symptom. It is something the patient experiences and reports, but it cannot be directly observed or measured by the nurse.
Choice C rationale
Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective finding. It can be observed by the nurse during a physical examination.
Choice D rationale
Fever is an objective finding. It can be measured by the nurse using a thermometer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Encouraging self-care is important, but it may not be the immediate priority if the patient is exhibiting manic behavior and has recently experienced significant personal stressors.
Choice B rationale
Assisting the patient in identifying coping behaviors is a key part of treatment, but it may not be the immediate priority if the patient is at risk of self-harm.
Choice C rationale
Preventing self-directed violence is the priority action. Patients exhibiting manic behavior may have impaired judgment and impulse control, putting them at risk of self-harm.
Choice D rationale
Identifying support systems is important, but it may not be the immediate priority if the patient is at risk of self-harm.
Correct Answer is ["2"]
Explanation
Step 1: Determine the amount of medication needed. The order is for 20 mEq of potassium chloride. The available amount is 10 mEq/mL.
Step 2: Calculate the volume of medication to administer. Volume = Ordered dose ÷ Available concentration Volume = 20 mEq ÷ 10 mEq/mL = 2 mL So, the nurse should administer 2 mL of potassium chloride suspension.
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