Nokea
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: Subjective data are information reported by the patient that cannot be observed or measured by others. In this case, choice C is correct because the patient describing excitement about discharge is personal and based on the patient's feelings or perceptions. This is subjective data because it is based on the patient's own experiences and emotions. Choices A and B are incorrect because patient's temperature and wound appearance are objective data that can be measured or observed by the nurse. Choice D is also incorrect as patient pacing the floor is an observable behavior, making it objective data. Therefore, choice C is the correct answer as it represents subjective data in the context of the assessment.
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Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?
- A. he passess formed stools at regular intervals
- B. he reports a decrease in stool frequency and liquidity
- C. he exhibits frim skin turgor
- D. he no longer experiences perianal burning
Correct Answer: C
Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.
While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining the client’s medication history, the nurse should determine if the client keeps which medication on hand?
- A. Diphenhydramine hydrochloride (Benadryl)
- B. Guaifenesin (Robitussin)
- C. Pseudoephedrine hydrochloride (Sudafed)
- D. Loperamide (Imodium)
Correct Answer: A
Rationale: Rationale:
A: Diphenhydramine hydrochloride (Benadryl) is an antihistamine commonly used to treat allergic reactions, including those from bee stings. It can help alleviate symptoms like itching and swelling. Keeping Benadryl on hand is crucial for managing an allergic reaction promptly.
Other Choices:
B: Guaifenesin (Robitussin) is an expectorant used to treat coughs, not allergic reactions.
C: Pseudoephedrine hydrochloride (Sudafed) is a decongestant used for nasal congestion, not allergic reactions.
D: Loperamide (Imodium) is an antidiarrheal used to treat diarrhea, not allergic reactions.
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: The correct answer is C because subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.
For a client in addisonian crisis, it would be very risky for a nurse to administer:
- A. potassium chloride.
- B. hydrocortisone.
- C. normal saline solution
- D. fludrocortisone.
Correct Answer: A
Rationale: The correct answer is A: potassium chloride. In Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone. Potassium levels are typically elevated in Addisonian crisis due to decreased aldosterone. Administering potassium chloride can further increase potassium levels, leading to life-threatening cardiac arrhythmias. Hydrocortisone (B) is essential to replace cortisol, normal saline solution (C) helps with volume resuscitation, and fludrocortisone (D) replaces aldosterone. Administering potassium chloride would exacerbate the hyperkalemia in Addisonian crisis.
What common problem is related to outcome identification and planning?
- A. Failing to involve the client in the planning process
- B. Collecting sufficient data to establish a database
- C. Stating specific and measurable outcomes based on nursing diagnoses
- D. Writing nursing orders that are clear and resolve the problem
Correct Answer: A
Rationale: The correct answer is A: Failing to involve the client in the planning process. This is because involving the client in the planning process is crucial for promoting client-centered care and ensuring that the outcomes are realistic and aligned with the client's goals. By engaging the client, the nurse can better understand their preferences and values, leading to more effective planning and goal setting.
Choice B is incorrect as collecting data to establish a database is related to assessment, not outcome identification and planning. Choice C is incorrect as stating specific and measurable outcomes based on nursing diagnoses is actually a key component of effective outcome identification and planning. Choice D is incorrect as writing clear nursing orders, although important, is more related to implementation rather than outcome identification and planning.