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Patient walks with a limp; Patient reports pain level as 3 on a scale of 1 to 10; Coughed up 5 mL yellow sputum; Headache in frontal area
The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)
- A. Assistive personnel reports the patient walks with a limp
- B. Patient reports pain level as 3 on a scale of 1 to 10
- C. Heart rate 72 beats per minute
- D. Respiratory rate 22 per minute with even unlabored respirations
- E. Coughed up 5 mL yellow sputum
- F. Headache in frontal area
Correct Answer: C,D,E
Rationale: C: Heart rate is measured, making it objective. D: Respiratory rate is observed and quantified, thus objective. E: Sputum volume and color are observable, hence objective. A is secondhand, B and F are subjective patient reports.
You may also like to solve these questions
To what does objective data refer when assessing a patient?
- A. the provider's observed data
- B. All of the answers are correct
- C. the patient's perception of provided data
- D. the patient's request for information
Correct Answer: A
Rationale: Objective data (A) includes measurable findings by the provider, like vital signs. C and D are subjective, and B is incorrect as only A is accurate.
During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?
- A. block
- B. by exception
- C. focused
- D. SOAP
Correct Answer: B
Rationale: Charting by exception (B) documents only significant changes or deviations, not routine care. Block (A) covers entire shifts, focused (C) targets specific issues, and SOAP (D) follows a structured format.
Patient with a nursing diagnosis of airway clearance, ineffective
The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:
- A. oxygen will be continued
- B. the patient's coughing frequency will increase
- C. cyanosis may be present
- D. within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea
Correct Answer: D
Rationale: The desired outcome for ineffective airway clearance (D) is measurable improvement, like no dyspnea within 24 hours. A is an intervention, B does not ensure clearance, and C indicates worsening.
How is Maslow's Hierarchy of Human Needs used by nurses in a clinical setting?
- A. It serves as a reminder of human growth and development across the life span
- B. It helps in prioritizing nursing diagnoses and care
- C. It outlines the basic psychological needs that people have when they are hospitalized and feel anxiety
- D. It is a framework for thinking critically
Correct Answer: B
Rationale: Maslow's hierarchy (B) prioritizes care by addressing physiological needs first, then safety, love, esteem, and self-actualization. A, C, and D are less accurate uses.
Patient with edema has a problem of fluid overload
The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)
- A. Teaching deep breathing and relaxation techniques as needed
- B. Inserting a nasogastric tube (NG) to relieve gastric distention
- C. Placing the nurse call button within reach at all times
- D. Giving hand massages daily
- E. Repositioning the patient every 2 hours to reduce pressure injury risk
- F. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed
Correct Answer: A,C,D,E
Rationale: A: Teaching non-pharmacological techniques is within a nurse's scope without a physician's order. C: Ensuring the call button is accessible promotes safety independently. D: Hand massages are a comfort measure nurses can provide independently. E: Repositioning prevents pressure injuries and is an independent action. B requires a physician's order, and F involves medication administration, which is dependent.