A nurse is documenting the data collected from a comprehensive physical exam of a client. Which of the following data should the nurse identify as objective data?

Choice A reason:

The size and depth of the ulcer are important indicators of the severity and healing progress of the wound. The nurse should measure the length, width, and depth of the ulcer using a ruler or a probe and document the findings. The nurse should also note the presence of any undermining or tunneling in the wound bed.

Choice B reason:

The presence of drainage or odor can signal infection or necrosis in the wound. The nurse should assess the amount, color, consistency, and odor of the drainage and document the findings. The nurse should also culture the wound if indicated and initiate appropriate wound care interventions.

Choice C reason:

The type and amount of pain medication administered are not directly related to the assessment of the pressure ulcer. Pain is a subjective experience that varies among individuals and situations. The nurse should assess the client's pain level using a valid pain scale and administer analgesics as prescribed, but this is not part of the ongoing assessment of the wound itself.

Choice D reason:

The client's nutritional status and intake are vital factors that affect wound healing. The nurse should assess the client's weight, body mass index, serum albumin, prealbumin, and transferrin levels, and dietary intake of protein, calories, vitamins, minerals, and fluids. The nurse should also provide nutritional supplements or consult a dietitian as needed to optimize the client's nutritional status.

Choice E reason:

The client's level of mobility and activity are also important factors that influence wound healing. The nurse should assess the client's ability to move, reposition, and ambulate independently or with assistance. The nurse should also implement measures to reduce pressure, shear, and friction on the wound site, such as using pressure-relieving devices, turning and repositioning the client frequently, and providing skin care.

Choice A reason:

Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.

Choice B reason:

Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.

Choice C reason:

Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.

Choice D reason:

Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.

Choice E reason:

Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.