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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The Joint Commission (TJC) is indeed known for providing accreditation to healthcare facilities. Accreditation by TJC is a mark of quality and signifies that a facility meets certain performance standards and complies with healthcare regulations. This accreditation process involves evaluating the quality and safety of care provided by the facility.
B. TJC does not monitor insurance claims. Instead, it focuses on accrediting and certifying healthcare organizations based on quality and safety standards. Monitoring insurance claims is typically the role of insurance companies or specific regulatory bodies related to insurance and billing practices, not TJC.
C. TJC does not provide licensure for healthcare providers. Licensure of healthcare professionals, such as nurses and physicians, is handled by state licensing boards or professional regulatory bodies, not by TJC. TJC’s role is primarily focused on accrediting healthcare facilities rather than licensing individuals.
D. The Joint Commission is a non-profit organization. It is dedicated to improving healthcare quality and safety through accreditation and certification. As a non-profit entity, TJC reinvests its resources into its mission to enhance the standards of care rather than focusing on generating profit.
Correct Answer is B
Explanation
A. While timing is important in delegation, it is not one of the five specific rights.
B. This is one of the five rights of delegation. Effective communication ensures that the AP clearly understands the task, expectations, and any necessary information. It also involves providing clear directions and feedback.
C. The room where the task is performed is not a factor in determining the appropriateness of delegation.
D. Documentation is a responsibility of the nurse, but it is not one of the five rights of delegation.
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