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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Correct Answer is ["A","B","C","D","E"]

Explanation

A. The site where the blood pressure was obtained is important to document because blood pressure measurements can differ significantly between different parts of the body (e.g., arm versus thigh). Documenting the site ensures that future measurements can be compared appropriately.
B. Interventions implemented in response to a client's blood pressure need documentation to track what actions were taken and whether these actions had the intended effect on the patient's health status. This helps in assessing the efficacy of interventions.
C. A client's position when the blood pressure was obtained affects the readings; measurements might differ when taken in positions such as lying, sitting, or

standing. Accurate documentation of position helps in ensuring that readings are interpreted correctly.
D. The frequency in which a blood pressure is taken provides context for understanding how the patient’s blood pressure is trending over time, which is critical for ongoing management and therapeutic decisions, especially in unstable or critical patients.
E. A client's response to interventions implemented should be documented to evaluate whether the treatment plan needs adjustments and to understand how the patient is coping with the treatment. This documentation is crucial for patient safety and care continuity.

A. Remove excess clothing from the client. B. Restrict the client's fluid intake. C. Place a warming blanket over the client. D. increase the temperature in the client's room.

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.

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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 assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

Correct Answer is ["A","B","C","D","E"]

Explanation

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

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