When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).
Urticaria.
Hypertension.
Diaphoresis.
Nausea.
Anxiety.
Edema.
Correct Answer : A,C,F
Choice A rationale:
Urticaria is a skin condition characterized by the sudden appearance of raised, itchy, and red welts on the skin. It is an objective finding because it can be observed and assessed visually. The presence of urticaria may indicate an allergic reaction or another underlying condition.
Choice B rationale:
Hypertension is a subjective finding because it cannot be directly observed. It requires blood pressure measurement to confirm, making it a subjective parameter.
Choice C rationale:
Diaphoresis refers to excessive sweating, which can be observed and assessed visually. It is an objective finding and may be indicative of various conditions, including anxiety or fever.
Choice D rationale:
Nausea is a subjective symptom because it is a sensation that the client experiences and reports. It cannot be directly observed by the nurse, making it a subjective parameter.
Choice E rationale:
Anxiety is a subjective symptom, as it is a mental and emotional state experienced by the client. It cannot be directly observed, making it a subjective parameter.
Choice F rationale:
Edema is an objective finding because it can be visually assessed by the nurse. Edema is the accumulation of excess fluid in body tissues, and its presence or absence can be objectively determined.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
Stopping the heparin infusion immediately is essential when the client's aPTT is significantly elevated (in this case, 120 seconds). A prolonged aPTT indicates a higher risk of bleeding, and discontinuing the heparin infusion is a crucial step in preventing further bleeding.
Choice B rationale:
Administering protamine sulfate is necessary when a client on heparin therapy experiences excessive bleeding or if the aPTT is significantly elevated. Protamine sulfate acts as a heparin antagonist and can reverse the anticoagulant effects of heparin.
Choice C rationale:
Notifying the healthcare provider of the significantly prolonged aPTT is essential because it may indicate a need for adjustments in the heparin dosage or therapy. The provider can determine the appropriate course of action based on the client's clinical condition.
Choice D rationale:
Drawing a prothrombin time (PT) and international normalized ratio (INR) level is not necessary in this situation. PT and INR are more relevant parameters when assessing clients on warfarin therapy, not heparin.
Choice E rationale:
Monitoring the client for signs and symptoms of bleeding is crucial when the aPTT is prolonged, as it indicates a higher risk of bleeding. This action allows for early detection and intervention to prevent complications.
Correct Answer is D
Explanation
Choice A rationale:
Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.
Choice B rationale:
Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.
Choice C rationale:
Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.
Choice D rationale:
Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.
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