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 B

Explanation

A: Tachypnea refers to rapid breathing, typically defined as a respiratory rate exceeding 20 breaths per minute.
B: Bradypnea is characterized by abnormally slow breathing, with a respiratory rate below the normal range.
C: Eupnea describes normal breathing, with a respiratory rate within the typical range for the patient's age and health status.
D: Apnea is the absence of breathing, not merely a decreased rate, and is considered a medical emergency.

A. The nurse applies pressure over a bony prominence of the foot for 2 seconds. B. The nurse percusses the tissue that appears edematous C. The nurse elevates the patient's feet on a pillow to decease swelling. D. The nurse charts, "Patient's feet appear to be swollen."

Correct Answer is A

Explanation

A: Applying pressure over a bony prominence helps assess for pitting edema, a common indicator of fluid retention causing swelling. This action provides objective data to confirm the patient's subjective observation.
B: Percussion is not typically used to assess edema. It is more suitable for assessing the density of underlying structures.
C: Elevating the feet may help alleviate swelling but does not confirm the presence of edema.
D: Documenting the observation is important, but further assessment is needed to confirm the patient's concern.

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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 assessing a sedated patient whose respiratory rate has fallen below 12 respirations per minute. The nurse identifies this condition as

Correct Answer is B

Explanation

The nurse enters the patient's room and the patient states, "I think my feet are swollen.". Which would be the nurse's next action?

Correct Answer is A

Explanation

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