During a health assessment, a client complains of palpitations. Which of the following is subjective data?

Vomiting.

Blood pressure reading.

Auscultation of heart murmur.

Client’s complaint of palpitations.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Vomiting is objective data as it can be observed and measured by the nurse.
Choice B rationale
Blood pressure reading is objective data as it is a measurable and observable finding.
Choice C rationale
Auscultation of heart murmur is objective data as it is an observable finding during a physical examination.
Choice D rationale
Client’s complaint of palpitations is subjective data as it is based on the client’s personal experience and cannot be directly observed or measured by the nurse.

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Correct Answer is B

Explanation

Choice A rationale
A Do Not Resuscitate (DNR) order is a type of advance directive that specifies that CPR should not be performed if the patient’s heart stops.
Choice B rationale
A trust fund is not a type of advance directive. It is a financial arrangement that does not relate to medical decisions.
Choice C rationale
A durable power of attorney for healthcare is a type of advance directive that allows an individual to appoint someone to make medical decisions on their behalf.
Choice D rationale
A living will is a type of advance directive that outlines an individual’s preferences for medical treatment in certain situations.

A. Notify the surgeon and clarify the discrepancy before proceeding. B. Proceed with the planned procedure as written. C. Discuss the discrepancy with the patient after the surgery. D. Ignore the discrepancy as it is not significant.

Correct Answer is A

Explanation

Choice A rationale
Notifying the surgeon and clarifying the discrepancy before proceeding is crucial to ensure patient safety. The time-out procedure is designed to prevent wrong-site, wrong-procedure, and wrong-person surgeries. Any discrepancy must be resolved to avoid potential harm to the patient.
Choice B rationale
Proceeding with the planned procedure as written without addressing the discrepancy can lead to serious errors, such as performing surgery on the wrong site or patient. This action is not aligned with the safety protocols established by the Joint Commission.
Choice C rationale
Discussing the discrepancy with the patient after the surgery does not prevent the error from occurring. The purpose of the time-out procedure is to catch and correct any discrepancies before the surgery begins.
Choice D rationale
Ignoring the discrepancy as it is not significant undermines the entire purpose of the time-out procedure, which is to ensure all details are correct before proceeding with surgery. Even seemingly minor discrepancies can lead to major errors.

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During a health assessment, a client complains of palpitations. Which of the following is subjective data?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is NOT a type of advance directive?

Correct Answer is B

Explanation

During a time-out procedure before surgery, what should the nurse do if there is a discrepancy?

Correct Answer is A

Explanation

A nurse is teaching a client about medication administration. The client is unable to read the instructions on the medication after discharge. What should the nurse do?

What is the primary purpose of a Healthcare Proxy?

What is the primary purpose of a safety event report?

A nurse on a medical-surgical unit has received a report on four clients. Which of the following clients should the nurse assign to the RN?

A nurse is planning a community smoking cessation management program. Which of the following SMART goals should the nurse set for the client?

A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply.

A nurse is providing teaching to a newly diagnosed diabetic patient. The nurse recognizes this as which learning domain?

A nurse on a medical-surgical unit is preparing to contact a provider about a client’s condition. The nurse notes the client’s post-op pain is 8/10, BP is 140/90, and HR is 110. The nurse should include information about the client in which component of the SBAR report?