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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Blood pressure of 90/60 mmHg
Rationale: A blood pressure of 90/60 mmHg indicates hypotension, which is a sign of septic shock and requires immediate intervention. Hypotension results from vasodilation and fluid loss due to the systemic inflammatory response to infection.
Incorrect options:
A) Temperature of 38.5°C (101.3°F) - This is a sign of fever, which is a common symptom of sepsis, but not as urgent as hypotension.
B) Heart rate of 110 beats per minute - This is a sign of tachycardia, which is a compensatory mechanism to maintain cardiac output in sepsis, but not as urgent as hypotension.
D) Respiratory rate of 22 breaths per minute - This is within the normal range for adults and does not indicate respiratory distress.
Correct Answer is C
Explanation
"What day of the week and month of the year is it?"
Rationale: Orientation is the awareness of one's personal identity, location, and time. Asking the client what day of the week and month of the year it is can help to assess the client's orientation to time.
Incorrect options:
A) "What is your name and date of birth?" - This question can help to assess the client's orientation to person, but not to location or time.
B) "Do you know where you are and why you are here?" - This question can help to assess the client's orientation to place, but not to person or time.
D) "Do you have any thoughts of harming yourself or others?" - This question can help to assess the client's suicidal or homicidal ideation, but not their orientation.
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