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 A

Explanation

A. This client needs IV pain medication, which requires advanced skills and knowledge to manage and administer safely. This situation involves complex and sensitive care, including pain management and end-of-life issues. RNs are typically responsible for administering IV medications, especially in critical or end-of-life situations.
B. A client who is 3 days postoperative and needs a dressing change generally requires a level of care that may be suitable for LPNs. LPNs are trained to perform dressing changes and manage postoperative wounds. However, if there are complications or concerns about the wound or the client’s condition, the RN should oversee or handle the situation.
C. Frequent ambulation can be managed by assistive personnel (AP) under the supervision of the RN. This task typically involves supporting and assisting the client with walking, which is within the scope of AP duties. LPNs can also assist with ambulation, but it is generally a task appropriate for APs when performed as part of routine care.
D. A client in protective isolation requires careful attention to infection control practices to protect them from infections. While the RN is responsible for ensuring adherence to isolation protocols and assessing the client’s needs, the day-to-day care tasks might be managed by LPNs and APs, provided they are trained in infection control procedures.

A. Advocacy B. Accountability C. Confidence D. Fairness

Correct Answer is B

Explanation

A. Advocacy involves protecting the client's rights and interests. While the nurse is acting in the client's best interest by assessing and reporting the error, the primary action here is taking responsibility.
B. Accountability is taking responsibility for one's actions and their consequences. By admitting the medication error, assessing the client, notifying the provider, and completing an incident report, the nurse is demonstrating accountability for their actions.
C. Confidence is believing in one's abilities. While confidence is important in nursing, it is not the primary characteristic displayed in this scenario.
D. Fairness involves treating everyone equally. This is not directly related to the nurse's actions in this case.

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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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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.)