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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. While acting as a mediator between the client and the provider is an important aspect of advocacy and communication, it is not directly related to accountability. Mediation involves facilitating communication and resolving conflicts, which are important for effective care but do not specifically address taking responsibility for one's own actions and decisions.
B. This is an example of accountability. Following the rights of medication administration—such as checking the right patient, medication, dose, route, and time—is a critical responsibility of the nurse. Ensuring that these rights are adhered to demonstrates accountability in medication management, as the nurse is taking responsibility for administering medications safely and correctly.
C. Supporting a client’s right to refuse medication is an important aspect of patient autonomy and ethical practice. While it reflects respect for the client’s choices and rights, it is more related to advocacy and ethical principles rather than directly demonstrating accountability for one’s own actions.

D. Ensuring that a client understands the adverse effects of their medication involves educating the client and ensuring informed consent. This is an important aspect of patient education and care but is not solely an example of accountability. Accountability would involve taking responsibility for making sure that this education is provided correctly and thoroughly.

A. A client who was admitted for chest pain and is reporting a new onset of indigestion B. A client who had a blood glucose reading at 0650 of 70 mg/dL after receiving 50% dextrose for a hypoglycemic episode C. A client who has pneumonia and was treated for a temperature of 38.9° C (102° F) at 0400 D. A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800

Correct Answer is A

Explanation

A. This client should be assessed first. Chest pain is a serious symptom that could indicate a cardiac event. The new onset of indigestion, even if unrelated, warrants immediate assessment to rule out any cardiac complications.
B. While hypoglycemia is a serious condition, the client's blood glucose is now within a normal range after treatment. This client can be assessed after the client with chest pain.
C. Pneumonia is a serious condition, but the client's temperature has been managed, and there is no indication of immediate instability. This client can be assessed after the first two.
D. While the IV catheter needs to be replaced, this is not an emergent situation. The client can receive the famotidine orally until the IV is replaced.

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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.)

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(Select All that Apply.)