A client with pneumonia has an oxygen saturation level of 88%. What is the priority intervention?

A. Respiratory rate measured at 22/min is observable, measurable, and obtained through direct assessment by the nurse. Objective data are factual findings that can be seen, heard, felt, or measured independently of the client’s perception.

B. Feeling anxious is a personal emotional experience described by the client. Subjective data rely on the client’s verbal report and cannot be directly measured or validated by the nurse.

C. Pain rated as 3 out of 10 reflects the client’s personal perception of discomfort. Although a scale is used, pain intensity is subjective because only the client can describe it.

D. Information provided by the partner is still based on reported experience rather than direct measurement by the nurse. This makes it subjective data, even though it comes from a secondary source.

A. Stage II: Stage II pressure injuries involve partial-thickness skin loss with exposed dermis. The injury may present as a blister, shallow ulcer, or abrasion. Since the skin in this case is intact, it does not meet Stage II criteria.

B. Stage IV: Stage IV pressure injuries are full-thickness tissue losses with exposed bone, tendon, or muscle. This severe stage is accompanied by extensive tissue damage, which is not present in this scenario.

C. Stage III: Stage III injuries involve full-thickness skin loss with damage or necrosis of subcutaneous tissue. The injury may extend down to, but not through, underlying fascia. The intact skin observed here does not qualify as Stage III.

D. Stage I: Stage I pressure injuries are characterized by non-blanchable erythema of intact skin, usually over a bony prominence. This is the earliest stage and indicates localized tissue damage without loss of skin integrity, matching the scenario described.