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 A

Explanation

A. Ongoing assessment: Ongoing assessments are continuous evaluations performed throughout the nurse's shift to monitor the client's status, response to interventions, and to adjust the care plan as needed.

B. Focused assessment: A focused assessment is targeted on a specific problem or area of concern, rather than a general or comprehensive evaluation.

C. Emergency assessment: An emergency assessment is rapid and focuses on identifying life-threatening conditions or urgent needs. It is not a routine, ongoing assessment.

D. Comprehensive assessment: A comprehensive assessment is an in-depth evaluation of the client's overall health status, usually performed upon admission or during initial evaluation. It is not typically repeated throughout the shift.

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

Naxlex Comprehensive Predictor Exams

Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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