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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.
Choice B rationale
Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.
Choice C rationale
Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.
Choice D rationale
Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.
Correct Answer is D
Explanation
Choice A rationale
Taking ibuprofen with aspirin is not typically recommended without a doctor’s advice. Both are nonsteroidal anti-inflammatory drugs (NSAIDs), and taking them together increases the risk of side effects such as stomach bleeding.
Choice B rationale
Ibuprofen is not used for stroke prevention. Aspirin, not ibuprofen, is often used for this purpose because of its antiplatelet effect.
Choice C rationale
Crushing sustained-release forms of medication is generally not recommended because it can lead to a rapid release and absorption of the drug, which increases the risk of side effects.
Choice D rationale
Taking ibuprofen with food is often recommended to reduce the risk of stomach upset.
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