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A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data?
- A. The patient complains of chest pain.
- B. The patient states "I am having trouble breathing."
- C. The patient complains of coughing up sputum.
- D. The patient expectorates red-tinged sputum.
Correct Answer: D
Rationale: Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Expectoration of red-tinged sputum is the only objective assessment finding. All other options are examples of subjective data.
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During a head-to-toe assessment the nurse assesses the patient's perineal area. Which area should the nurse assess next?
- A. Chest
- B. Arms
- C. Abdomen
- D. Legs and feet
Correct Answer: D
Rationale: When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.
During a physical assessment the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Coughing
- D. Ecchymosis
Correct Answer: C
Rationale: Coughing is a sudden audible expulsion of air from the lungs. Coughing is an essential protective response that serves to clear the lungs, bronchi, or trachea of irritants and secretions or to prevent aspiration of foreign material into the lungs. It is a common sign of diseases of the larynx, bronchi, and lungs.
The patient should be assessed as soon as possible after admission. Who performs this initial assessment?
- A. Health care provider
- B. Charge nurse
- C. LPN/LVN
- D. RN
Correct Answer: D
Rationale: The initial assessment is done by the registered nurse.
A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds the nurse identifies 2+ pitting edema. When did the edema disappear?
- A. 10 to 15 seconds
- B. 20 to 25 seconds
- C. 30 to 35 seconds
- D. 40 to 45 seconds
Correct Answer: A
Rationale: The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds.
What should a patient interview being conducted by the nurse convey to the patient?
- A. The nurse has feelings of concern.
- B. The nurse has limited time.
- C. The nurse is very intelligent.
- D. The nurse has answers to problems.
Correct Answer: A
Rationale: The nurse must convey feelings of concern.