At the end of the shift, the nurse documents that the client has voided 475 ml during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Covert

Subjective

Objective

Symptomatic

Answer and Explanation

The Correct Answer is C

A. Covert: Covert data refers to information that is hidden, subjective, or not immediately observable, such as symptoms reported by the client. Voided volume is measurable and observable, so it is not covert.

B. Subjective: Subjective data is information reported by the client, such as feelings, perceptions, or symptoms. Since the urine output is a measurable and observable fact, it is not subjective.

C. Objective: Objective data is factual, measurable, and observable. The voided volume of 475 ml is a precise, quantifiable measurement, making it objective data.

D. Symptomatic: Symptomatic data pertains to symptoms experienced by the client, which are typically subjective. The documented urine output is a specific, quantifiable measurement and not a symptom.

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Correct Answer is B

Explanation

A. Administer oxygen at 2 L/min: Administering oxygen is important but should be done after positioning the client to improve natural ventilation.

B. Raise the head of the bed: Raising the head of the bed is the first action to take as it facilitates better lung expansion and improves ventilation. This can help increase the oxygen saturation more immediately and effectively.

C. Encourage coughing and deep breathing: Encouraging coughing and deep breathing is also beneficial to help clear secretions and improve lung function, but positioning the client for optimal breathing should be prioritized first.

D. Administer prescribed analgesic medication. Administering analgesics may be necessary for pain management, but it does not directly address the immediate need to improve oxygen saturation.

A. Document "impaired oxygenation" on the nursing care plan. B. Auscultate the chest for breath sounds. C. Collaborate with the client to form goals. D. Apply supplemental oxygen by face mask as needed.

Correct Answer is B

Explanation

A. Document "impaired oxygenation" on the nursing care plan: While this may be appropriate based on assessment findings, it's premature to document without conducting a thorough assessment first.

B. Auscultate the chest for breath sounds: This is a critical component of assessing respiratory function, especially in a client with pneumonia, to identify abnormal breath sounds such as crackles or diminished breath sounds.

C. Collaborate with the client to form goals: Goal setting typically comes after assessment data is collected and analyzed.

D. Apply supplemental oxygen by face mask as needed: This action should be based on assessment findings indicating the need for oxygen therapy, not assumed without assessment.

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At the end of the shift, the nurse documents that the client has voided 475 ml during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Nursing Test Bank

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