A nurse is documenting the findings of a head-to-toe assessment on a client who has been hospitalized for pneumonia.

Which statement by the nurse reflects the appropriate use of objective data?

"The client reports feeling short of breath and fatigued."

"The client has crackles in the lower lobes bilaterally."

"The client states that he has been coughing up green sputum."

"The client rates his pain as 4 out of 10 on a numeric scale."

Answer and Explanation

The Correct Answer is B

"The client has crackles in the lower lobes bilaterally."

Rationale: Objective data are observable and measurable facts that can be verified by the nurse or another health care provider. Crackles are an abnormal lung sound that can be heard with a stethoscope and indicate fluid accumulation in the alveoli.

Incorrect options:

A) "The client reports feeling short of breath and fatigued." - This is an example of subjective data, which are information that only the client can perceive and describe, such as feelings, sensations, and beliefs.

C) "The client states that he has been coughing up green sputum." - This is also an example of subjective data, as it is based on the client's verbal report.

D) "The client rates his pain as 4 out of 10 on a numeric scale." - This is another example of subjective data, as pain is a personal experience that cannot be directly measured by the nurse.

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Correct Answer is B

Explanation

Glycosylated hemoglobin (HbA1c) of 8%

Rationale: Glycosylated hemoglobin (HbA1c) reflects the average blood glucose level over the past two to three months. A normal HbA1c level is less than 5.7%, while a level above 6.5% indicates diabetes. A level of 8% or higher indicates poor glycemic control and increased risk of complications.

Incorrect options:

A) Fasting blood glucose of 126 mg/dL - This is a borderline value that may indicate prediabetes, but not necessarily poor glycemic control. A fasting blood glucose of 126 mg/dL or higher on two separate occasions is diagnostic of diabetes.

C) Random blood glucose of 180 mg/dL - This is an elevated value that may indicate hyperglycemia, but not necessarily poor glycemic control. A random blood glucose of 200 mg/dL or higher with symptoms of diabetes is diagnostic of diabetes.

D) Urine ketones of negative - This is a normal finding that indicates the absence of ketones in the urine. Ketones are produced when the body breaks down fat for energy due to insufficient insulin. The presence of ketones in the urine indicates diabetic ketoacidosis, a life-threatening complication of diabetes.

A. Use a filter needle to draw up the medication from the vial B. Use a non-latex glove to palpate the injection site C. Use an alcohol swab to cleanse the injection site D. Use a Z-track technique to inject the medication

Correct Answer is B

Explanation

Use a non-latex glove to palpate the injection site

Rationale: The nurse should use a non-latex glove to palpate the injection site, as latex gloves can cause skin irritation, rash, or anaphylaxis in clients who have a latex allergy.

Incorrect options:

A) Use a filter needle to draw up the medication from the vial - This action is not related to preventing an allergic reaction, but rather to preventing contamination or injury from glass particles that may be present in some vials.

C) Use an alcohol swab to cleanse the injection site - This action is not related to preventing an allergic reaction, but rather to preventing infection by reducing the number of microorganisms on the skin.

D) Use a Z-track technique to inject the medication - This action is not related to preventing an allergic reaction, but rather to preventing leakage or irritation of the medication into the subcutaneous tissue by creating a zigzag path with the needle.

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A nurse is documenting the findings of a head-to-toe assessment on a client who has been hospitalized for pneumonia. Which statement by the nurse reflects the appropriate use of objective data?

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A nurse is documenting the findings of a head-to-toe assessment on a client who has been hospitalized for pneumonia.

Which statement by the nurse reflects the appropriate use of objective data?