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When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

Urticaria.

Hypertension.

Diaphoresis.

Nausea.

Anxiety.

Edema.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Drinking electrolyte fluid replacements may be necessary if the client is dehydrated due to diabetic ketoacidosis (DKA). However, addressing the increased thirst, which is a sign of DKA, should involve insulin administration to correct the underlying problem of high blood sugar.

Choice B rationale:

Giving a dose of regular insulin as prescribed is the most appropriate action to address increased thirst in a client with type 1 diabetes and early signs of DKA. Elevated blood sugar levels are the cause of the increased thirst, and insulin helps lower blood sugar levels.

Choice C rationale:

Resuming normal physical activity may not be advisable when a client is experiencing early signs of DKA. Strenuous physical activity can exacerbate hyperglycemia, and the primary focus should be on insulin administration and rehydration.

Choice D rationale:

Measuring urine output over the next 24 hours is important for monitoring hydration status in a client with DKA. However, the immediate priority is to address the increased thirst and hyperglycemia with insulin therapy.

A. Instill 3 mL of normal saline before suctioning. B. Instruct the client to cough as the suction tip is removed. C. Apply a water-soluble lubricant to the catheter. D. Wear protective goggles while performing the procedure. E. Wear protective goggles while performing the procedure.

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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When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Correct Answer is B

Explanation

The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

Correct Answer is D

Explanation

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