A nurse on the Cardiovascular unit is completing the patient's history and physical examination. Which of the following information provided by the patient should the nurse consider as subjective data?
Cyanosis.
Petechiae.
Dizziness.
Blood pressure.
The Correct Answer is C
Choice A rationale:
Cyanosis - Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. This is an objective sign that can be visually assessed, not based on the patient's description.
Choice B rationale:
Petechiae - Petechiae are small, pinpoint, red or purple spots on the skin caused by bleeding under the skin. Like cyanosis, this is a physical finding that can be observed directly.
Choice C rationale:
Dizziness - This is the correct choice. Dizziness is a subjective sensation that the patient experiences. It cannot be directly observed and relies on the patient's description of feeling unsteady, lightheaded, or having a spinning sensation.
Choice D rationale:
Blood pressure - Blood pressure is an objective measurement that can be taken using a blood pressure cuff and a stethoscope or automated device. It is not based on the patient's description and does not fall under subjective data.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Instructing the client not to adjust the oxygen flow rate is crucial to ensure the appropriate amount of oxygen is delivered. Oxygen flow rates are prescribed by a healthcare provider based on the client's needs, and altering the flow rate without medical guidance can lead to inadequate oxygen delivery or oxygen toxicity.
Choice B rationale:
Weekly equipment checks are important, but this choice is not the most critical instruction. Clients should be instructed to check their oxygen equipment daily for proper functioning and to address any issues promptly. Waiting a whole week could lead to potential problems going unnoticed.
Choice C rationale:
Storing unused oxygen tanks horizontally is incorrect. Oxygen tanks should be stored upright to prevent leaks and ensure proper functioning. Storing them horizontally can cause valve damage and leakage, which could lead to hazards.
Choice D rationale:
Using wool blankets on the bed is not a suitable instruction for a client using oxygen therapy. Wool blankets can generate static electricity, which might pose a fire hazard in the presence of oxygen-enriched environments.
Correct Answer is B
Explanation
Choice A rationale:
Reporting the incident to the charge nurse is important, but it's not the first action to take in this situation. The immediate concern should be addressing the potential exposure to bloodborne pathogens.
Choice B rationale:
This is the correct choice. Washing the area of the puncture thoroughly with soap and water is the first step the nurse should take after an accidental needlestick. It helps reduce the risk of infection by cleaning the wound and removing any potential contaminants.
Choice C rationale:
Going to employee health services is a valid step, but it's not the immediate action needed after an accidental needlestick. Cleaning the wound should come first.
Choice D rationale:
Completing an incident report is important for documentation purposes, but it is not the nurse's first priority in this situation. Immediate wound care takes precedence.
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