A nurse is documenting data collection findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)
Client reports the rash on their back is itchy
Client reports nausea following administration of pain medication.
Client has a raised, red rash on their upper back.
Client reports dull, aching pain in lower right calf.
Client's oral temperature is 38.4° C (101.2° F).
Correct Answer : A,B,D
A. This entry reflects the client’s personal experience and perception of the rash. It is not measurable and relies on the client’s description.
B. This statement is also based on the client’s experience and feelings about their condition after taking medication. It is a personal report and not an observable finding.
C. This is an observation made by the nurse. The description of the rash is measurable and can be documented as a physical finding.
D. Similar to options A and B, this entry describes the client’s perception of pain. It is a personal
experience that cannot be directly measured.
E. This is a measurable finding obtained through a thermometer. It provides concrete evidence of the
client’s condition and does not rely on the client’s report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["E"]
Explanation
A. This reflects primary care. Teaching clients about exercise is aimed at promoting health and preventing disease, which is a fundamental aspect of primary healthcare.
B. This also pertains to secondary care. Regular exams are important for early detection of health issues, helping to catch problems before they become more serious. This activity does not reflect tertiary care.
C. This activity is related to secondary care. A mammogram is a screening tool used for early detection of breast cancer. Assisting with this procedure does not represent tertiary care, as it focuses on prevention and early diagnosis rather than treatment of an established condition.
D. This is another example of primary care. Educating clients about safe habits is aimed at promoting health and preventing injury or illness, which aligns with primary prevention efforts.
E. This is the correct choice and reflects tertiary care. Transplant surgery is a complex procedure that involves specialized medical intervention for individuals with severe health conditions. It is focused on treatment after a disease has progressed, which is characteristic of tertiary care.
Correct Answer is A
Explanation
A. The nurse should wear a surgical mask when within 0.6 m (2 ft) of the client to prevent the spread of infection. This is one of the key precautions for droplet isolation.
B. Clients who are placed on droplet precautions should wear a surgical mask when they leave their room to prevent the spread of infection to others. However, it is not necessary for the nurse to place a mask on the client.
C. Clients who are placed on droplet precautions should be isolated in a private room or in a room with other clients who have the same infection. A positive airflow room is typically used for clients who are immunocompromised or have airborne infections.
D. Fresh flowers do not pose a significant risk of infection transmission and can be kept in the client's room.
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