Which of these assessment findings should a nurse record as subjective?

Hives.

Itching.

Vomiting.

Abdominal distension.

Answer and Explanation

The Correct Answer is B

This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the

patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.

For example:

Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.

Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.

Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.

Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:

Hives: No hives or rashes on the skin are normal.
Vomiting: No vomiting or nausea are normal.
Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).

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Correct Answer is A

Explanation

Notify the health care provider to report and anticipate new orders.

This is because an oral temperature of 100.8° F (38.2° C) indicates a fever, which could be a sign of infection or inflammation in an elderly client.

A fever of this magnitude could also cause dehydration, confusion, or seizures in older adults.

Therefore, the nurse should notify the health care provider as soon as possible to determine the cause and treatment of the fever.

Choice B is wrong because covering the client with an additional blanket could increase the body temperature and worsen the fever.

The UAP should not recheck the temperature in two hours, but rather monitor it more frequently and report any changes to the nurse.

Choice C is wrong because charting the temperature on the vital signs sheet and reporting to the new shift coming on is not enough to address the urgency of the situation.

The nurse has a responsibility to act on abnormal findings and communicate them to the health care provider.

Choice D is wrong because assessing the client’s temperature rectally and comparing the results is not necessary and could cause discomfort or injury to the client.

Rectal temperatures are usually higher than oral temperatures by about 0.5° F (0.3° C), so this would not change the interpretation of the fever.

The normal range for oral temperature in adults is 97.6° F to 99.6° F (36.4° C to 37.6° C).

A. Oatmeal with a banana, milk, and orange juice. B. Blueberry muffin, cranberry juice, and herbal tea. C. Scrambled egg whites, whole wheat toast, and apple juice. D. Bagel with low fat cream cheese and decaffeinated coffee.

Correct Answer is C

Explanation

This is because furosemide is a diuretic that makes you pee more and lose water and electrolytes such as potassium and sodium.

Therefore, you should avoid foods that are high in sodium or potassium, such as bananas, oranges, cranberries, and bagels with cream cheese.

You should also drink plenty of fluids to prevent dehydration.

Choice A is wrong because oatmeal with a banana, milk, and orange juice contains too much potassium, which can cause irregular heartbeat or muscle weakness when taking furosemide.

Choice B is wrong because blueberry muffins, cranberry juice, and herbal tea contain too much sodium and sugar, which can raise your blood pressure and worsen your heart failure.

Choice D is wrong because a bagel with low-fat cream cheese and decaffeinated coffee contains too much sodium and caffeine, which can cause fluid retention and increase your heart rate.

Normal ranges for potassium are 3.5 to 5.0 mmol/L and for sodium are 135 to 145 mmol/L.

You should monitor your electrolyte levels regularly when taking furosemide.

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Which of these assessment findings should a nurse record as subjective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C). Which action should a nurse take next?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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