A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

The patient has low blood pressure.

The patient is short of breath.

The patient has wound drainage.

The patient reports feelings of fatigue.

Answer and Explanation

The Correct Answer is D

A: Low blood pressure is an objective finding that can be measured directly.

B: Shortness of breath is a subjective symptom reported by the patient.
C: Wound drainage is an objective finding that can be observed directly.

D: Feelings of fatigue are subjective symptoms reported by the patient, reflecting their personal experience rather than directly observable physical signs.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A: This helps reduce body temperature by increasing heat loss through evaporation and radiation. Removing layers allows the body’s natural cooling mechanisms to function more effectively.
B: This would be inappropriate because adequate hydration is crucial for a febrile patient to help regulate body temperature and prevent dehydration.
C: This would be counterproductive as it would add heat to the body instead of helping to lower the body temperature.
D: Increasing the room temperature would worsen the situation by making the environment warmer, which would hinder the body's ability to cool down naturally.

A. Anisocoria of the patient's pupils. B. Patient's accommodation response. C. Direct pupil response of the patient. D. Patient's consensual reflex.

Correct Answer is B

Explanation

A: Anisocoria refers to a condition where the pupils are of unequal sizes, which is not related to focusing ability.

B: Accommodation response involves the ability of the eye to change focus from distant to near objects, demonstrating the flexibility of the lens which is exactly what the instruction aims to test.
C: Direct pupil response relates to pupil constriction in response to light, not changes in focal distance.
D: Consensual reflex also refers to the reaction of both pupils to light and would not be assessed through changes in focal distance.

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A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an oral temperature of 39.5°C (103.1°F). Which of the following actions should the nurse take?

Correct Answer is A

Explanation

The nurse gives the patient the following instructions: "Focus on the far wall and now focus on my pen." The nurse is assessing the

Correct Answer is B

Explanation

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