A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?

Temperature 38 C/100.4F, bowels sounds 15/minute

Nausea and stomach cramps.

Occasional cough, respiratory rate 18 breaths per minute

White blood cell count 14,000/mm3, pain 4/10

Answer and Explanation

The Correct Answer is B

A. Temperature and bowel sounds are measurable, making them objective data rather than subjective.

B. These symptoms cannot be measured or observed by the nurse; they are based on the patient's personal experience, making them subjective data.

C. While the cough is subjective, the respiratory rate is measurable and therefore objective. Since the option includes both types of data, it is not the best answer.

D. White blood cell count is objective. Pain rating is subjective, but since this option includes both types of data, it is not the best choice.

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Correct Answer is C

Explanation

A. Nurse’s lounge. This is incorrect because the nurse’s lounge is not a private or appropriate setting for a report. It may not be secure, and other personnel who are not directly involved in the client’s care may overhear confidential information, which violates privacy regulations such as HIPAA.

B. Conference area. This is incorrect because, while a conference room provides some privacy, bedside reporting is preferred as it allows for direct patient involvement, immediate clarification, and continuity of care.

C. Client’s bedside. This is correct because bedside reporting enhances communication, ensures the oncoming nurse can visually assess the client, and allows the client to participate in their care. This approach promotes safety and reduces the risk of errors during the handoff.

D. Outside client’s room. This is incorrect because it does not ensure privacy and may not allow for direct verification of client information. Discussing a report outside the room could also expose confidential information to unintended listeners.

A. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed B. Administering pain-relief medication according to what was given last shift C. Offering pain-relief medication based on the health care provider's orders D. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past

Correct Answer is D

Explanation

A. Pain is subjective, and patients experience it differently. Dismissing their report based on the procedure undermines their experience and may lead to inadequate pain management.

B. Pain levels fluctuate, and treatment should be based on current assessment rather than past administration. This approach lacks critical thinking and fails to address the patient's individual needs.

C. While following provider orders is necessary, blindly administering medication without assessing the patient's current pain level and preferences is not critical thinking.

D. This approach individualizes care and involves the patient in decision-making, which is a key component of critical thinking in nursing.

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A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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