A nurse is assessing a client who is postoperative.. Which of the following findings should the nurse identify as objective data?

(Select All that Apply.)

The client's current blood pressure is below their preoperative reading.

The client's right calf is swollen and warm to the touch.

The client is reporting nausea.

The client states they are experiencing "extreme pain".

The client's urine output has been 150 mL over the past 3 hr.

Answer and Explanation

Correct Answer : A,B,E

A.   Blood pressure is a measurable physiological parameter that can be accurately recorded by the nurse using a sphygmomanometer. It provides concrete evidence of the client’s current condition compared to their preoperative baseline.
B.   The swelling and warmth of the calf are observable and measurable physical signs that the nurse can assess through physical examination. These findings can be documented and evaluated independently of the client's personal feelings or reports.
C.   Nausea is a symptom experienced and reported by the client. It cannot be directly measured or observed by the nurse but rather is based on the client's personal sensations and experiences.
D.   Pain is a personal experience and is reported by the client. The description of pain, including its intensity and quality, is based on the client's own perception and cannot be directly measured by the nurse.
E.   Urine output is a quantifiable measurement that can be recorded and assessed by the nurse. It
provides concrete information about the client’s fluid balance and renal function over a specific period.

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Correct Answer is D

Explanation

A. Monitoring blood glucose is crucial for managing diabetes, as it directly affects the child's blood sugar levels and overall well-being. However, if the child’s blood glucose levels are stable and there are no immediate concerns or symptoms, this task, while important, may not be as urgent as assessing more critically ill clients.
B. While discharge instructions are important for ensuring proper care after leaving the hospital, this task generally does not require immediate attention compared to assessing a client with more acute or urgent needs. The adolescent is ready for discharge, indicating their condition is stable enough to prepare for leaving the unit.
C. Feeding a toddler who has both arms in casts is important for ensuring that the child is well-nourished and comfortable. However, this task can usually be managed by assistive personnel or done at a scheduled time without immediate urgency compared to more critical assessments.
D. An infant with pertussis (whooping cough) receiving oxygen via nasal cannula is in a potentially critical situation. Pertussis can cause significant respiratory distress, and the need for oxygen indicates the
infant’s respiratory function is compromised. Assessing this infant first is crucial to ensure that the oxygen therapy is effective and to monitor for any signs of deterioration in respiratory status.

A. A private room in a quiet location on the unit B. A seclusion room until the client's activity level becomes more subdued. C. A semi-private room with a roommate who has a similar diagnosis D. A private room close to the nursing station

Correct Answer is D

Explanation

A. While a quiet environment is generally desirable for patients, a client in a manic phase often experiences increased energy and agitation. A quiet room might not adequately address their need for constant monitoring.
B. Seclusion should be used as a last resort and only in cases where the client poses an immediate danger to themselves or others. It is not appropriate for routine management of mania.
C. While it might seem helpful to pair patients with similar conditions, a manic patient can be disruptive to roommates, affecting their well-being and potentially escalating their own symptoms.
D. This option is the most appropriate. A private room provides necessary privacy and space, while proximity to the nursing station allows for close observation and rapid intervention if needed.

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A nurse is assessing a client who is postoperative.. Which of the following findings should the nurse identify as objective data? (Select All that Apply.)

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A nurse is assessing a client who is postoperative.. Which of the following findings should the nurse identify as objective data?

(Select All that Apply.)