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).

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. This activity is related to primary prevention, focusing on health promotion and preventing illness. It aims to educate clients on lifestyle choices that can prevent health problems.
B. Tertiary care involves specialized treatments and interventions for severe or complex health issues. Assisting with transplant surgery is a highly specialized procedure that falls under tertiary care, as it addresses advanced medical conditions requiring significant intervention.
C. Similar to option A, this activity focuses on health promotion and prevention. Teaching about exercise programs is part of primary care, aiming to improve overall health and prevent future health issues.
D. This activity is part of secondary care. Recommending regular exams is aimed at early detection of potential health issues, allowing for timely intervention. It does not reflect the specialized care provided in tertiary healthcare.

A. Dispose of used razors in wastebaskets. B. Use two hands to recap a needle after administering a medication. C. Break needles on syringes before disposal. D. Replace sharps containers when they are full.

Correct Answer is D

Explanation

A. Used razors should never be disposed of in regular wastebaskets as they pose a significant risk for puncture injuries. Instead, they should be placed in a designated sharps container to prevent accidental cuts or injuries to anyone handling the waste.
B. The practice of using two hands to recap a needle is not recommended because it increases the risk of a needlestick injury. Instead, nurses should use a one-handed technique or a safety device designed for recapping needles to minimize the risk of injury.
C. Needles should not be broken off from syringes before disposal, as this can create sharp edges that can puncture the skin and lead to injuries. Instead, syringes with needles should be disposed of intact in a designated sharps container.
D. Sharps containers should be replaced when they are full to ensure safe disposal of needles and other sharp instruments. Overfilled containers can pose a risk of needlestick injuries and may not allow for proper disposal of new sharps.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing activity reflects care given on the tertiary level of healthcare delivery?

Correct Answer is B

Explanation

A nurse is assisting with teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

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