Nokea
A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data?
- A. Blood pressure
- B. Cyanosis
- C. Nausea
- D. Petechiae
Correct Answer: C
Rationale: Subjective data are information reported by the client, such as symptoms or feelings. Nausea is subjective because the client experiences and reports it. Blood pressure, cyanosis, and petechiae are objective data that can be measured or observed directly by the nurse. Blood pressure is a vital sign, cyanosis is a physical finding, and petechiae are skin manifestations. Therefore, they are not subjective data. By understanding the distinction between subjective and objective data, the nurse can accurately assess and document the client's health status.
You may also like to solve these questions
A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.)
- A. Shallow respirations
- B. Cardiac dysrhythmias
- C. Flushing
- D. Hyperactive reflexes
- E. Abdominal pain
Correct Answer: A,B,D
Rationale: The correct answer is A, B, and D. In metabolic alkalosis, the blood pH is elevated due to an excess of bicarbonate. Shallow respirations (A) occur as a compensatory mechanism to retain CO2 and decrease pH. Cardiac dysrhythmias (B) can result from electrolyte imbalances associated with alkalosis. Hyperactive reflexes (D) are a sign of neuromuscular irritability due to altered electrolyte levels. Flushing (C) and abdominal pain (E) are not typically associated with metabolic alkalosis. In summary, the nurse should monitor for shallow respirations, cardiac dysrhythmias, and hyperactive reflexes in a client with metabolic alkalosis, as they are indicative of the condition and its complications.
A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?
- A. It delivers a specific concentration of oxygen constantly.
- B. It delivers the highest concentration of oxygen possible.
- C. It delivers the low concentration of oxygen you need.
- D. It allows you to remove it for a while when it gets uncomfortable.
Correct Answer: C
Rationale: The correct answer is C: It delivers the low concentration of oxygen you need. Nasal cannulas deliver a low flow rate of oxygen, typically between 1-6 liters per minute, providing a lower concentration of oxygen compared to other oxygen delivery devices. This is suitable for clients who require only a slight increase in their oxygen levels. Choice A is incorrect as nasal cannulas do not deliver a specific concentration of oxygen constantly. Choice B is incorrect as nasal cannulas do not deliver the highest concentration of oxygen possible. Choice D is incorrect because nasal cannulas should not be removed when uncomfortable as it disrupts the oxygen therapy.
A nurse is collecting data from a client who has depression to identify his ability to perform activities of daily living (ADLs) prior to discharge. Which of the following data should the nurse collect?
- A. Ability to perform oral hygiene
- B. Ability to bathe himself
- C. Ability to identify how often he should schedule his car for an oil change
- D. Ability to balance his bank account
- E. Ability to dress himself
Correct Answer: A,B,E
Rationale: Assessing ADLs includes evaluating self-care abilities like hygiene, bathing, and dressing.
A nurse is reinforcing dietary teaching with a client who wants to reduce solid fat intake. Which of the following instructions should the nurse include?
- A. Replace tub margarine with stick margarine.
- B. Use safflower oil instead of butter when baking.
- C. Consume 2% or whole milk.
- D. Choose ground beef that is at least 80% lean meat.
Correct Answer: B
Rationale: The correct answer is B: Use safflower oil instead of butter when baking. Safflower oil is a healthier alternative to butter as it is a liquid fat and contains unsaturated fats, which are better for heart health and reducing solid fat intake. Butter, on the other hand, is a solid fat high in saturated fats, which can increase cholesterol levels. This substitution promotes a lower intake of solid fats while still allowing for baking needs. The other choices are incorrect because: A) Stick margarine is also a solid fat high in trans fats, not suitable for reducing solid fat intake. C) Whole milk contains solid fats, so opting for low-fat or skim milk would be better. D) Ground beef with at least 80% lean meat still contains solid fats, so choosing leaner options like 90% lean or ground turkey would be more beneficial.
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client's respiratory secretions?
- A. Encourage the client to ambulate more often.
- B. Encourage coughing and deep breathing.
- C. Encourage the client to drink more fluids.
- D. Encourage regular use of the incentive spirometer.
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to drink more fluids. Increased fluid intake helps to thin respiratory secretions, making it easier for the client to cough them up and clear the airways. This action promotes effective airway clearance and reduces the risk of complications such as pneumonia worsening. Encouraging ambulation (A) is beneficial for overall lung health but does not directly address thinning of respiratory secretions. While coughing and deep breathing (B) are important for clearing secretions, increasing fluids is more effective in thinning them. Using the incentive spirometer (D) helps with lung expansion but does not directly thin secretions.