A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data?
(Select All that Apply.)
Client reports dull, aching pain in lower right calf.
Client reports nausea following administration of pain medication.
Client's oral temperature is 38.4° C (101.2° F).
Client reports the rash on their back is itchy.
Client has a vesicular rash on their upper back.
Correct Answer : A,B,D
A. This is subjective data. The description of pain as "dull" and "aching" is based on the client's personal experience and cannot be measured directly by the nurse. Pain is a subjective symptom because it varies from person to person and is reported by the patient.
B. This is subjective data. Nausea is a feeling or sensation reported by the client and is based on their personal experience. The nurse relies on the client's report to assess this symptom, as it cannot be directly observed or measured.
C. This is objective data. The temperature reading is a measurable, quantifiable fact that can be directly observed and recorded by the nurse using a thermometer. It provides concrete evidence of the client's condition.
D. This is subjective data. Itchiness is a sensation reported by the client and is based on their personal experience. The nurse cannot measure itchiness directly; they rely on the client’s description to understand the symptom.
E. This is objective data. The presence of a vesicular rash is an observable finding that the nurse can see and document. It is a physical characteristic that can be directly assessed and recorded.
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Related Questions
Correct Answer is C
Explanation
A. This task is generally appropriate for an assistive personnel (AP) if it is within their scope of practice and if proper training has been provided. Glucometer monitoring is a routine task that APs can often perform, assuming they are trained in using the glucometer and understanding the importance of accurate readings.
B. Assigning two APs to ambulate all clients might be seen as overdelegation if the task requires more clinical judgment or if there are other tasks that need to be managed concurrently. Ambulating clients can sometimes be complex depending on their condition, and it’s essential to ensure that APs are appropriately trained and that the workload is balanced.
C. Assigning a new graduate nurse to perform a wet-to-dry dressing change could be considered overdelegation if the task requires advanced skills and experience that the new graduate might not yet possess. Wet-to-dry dressing changes can be complex and require a certain level of expertise to ensure proper technique and patient safety.
D. This task is typically appropriate for an RN with the necessary competencies and experience. A central line dressing change requires specific skills and knowledge, and delegating this task to the most competent RN ensures that it is performed correctly and safely. This is not considered overdelegation because it matches the task to the skill level of the RN.
Correct Answer is B
Explanation
A. While delegation might contribute to more efficient use of resources and potentially reduce some costs, it is not the primary purpose of delegation. The main goal of delegation is to manage tasks and responsibilities more effectively, rather than focusing directly on cost reduction.
B. Delegation involves assigning specific tasks or responsibilities to others so that goals can be met more efficiently. It allows the delegating nurse to entrust certain tasks to others, enabling the overall objectives of patient care and unit management to be achieved effectively. This statement captures the essence of delegation as it involves empowering others to carry out tasks to achieve a common goal.
C. While delegation can help ensure that resources are used appropriately by assigning tasks to the right individuals, this statement is more about resource management rather than the primary purpose of delegation itself.
D. Delegation itself does not specifically promote discharge teaching activities. While tasks related to discharge teaching can be delegated, the primary purpose of delegation is broader, focusing on managing workload and achieving goals by assigning tasks to others.
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