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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. While acting as a mediator between the client and the provider is an important aspect of advocacy and communication, it is not directly related to accountability. Mediation involves facilitating communication and resolving conflicts, which are important for effective care but do not specifically address taking responsibility for one's own actions and decisions.
B. This is an example of accountability. Following the rights of medication administration—such as checking the right patient, medication, dose, route, and time—is a critical responsibility of the nurse. Ensuring that these rights are adhered to demonstrates accountability in medication management, as the nurse is taking responsibility for administering medications safely and correctly.
C. Supporting a client’s right to refuse medication is an important aspect of patient autonomy and ethical practice. While it reflects respect for the client’s choices and rights, it is more related to advocacy and ethical principles rather than directly demonstrating accountability for one’s own actions.

D. Ensuring that a client understands the adverse effects of their medication involves educating the client and ensuring informed consent. This is an important aspect of patient education and care but is not solely an example of accountability. Accountability would involve taking responsibility for making sure that this education is provided correctly and thoroughly.

A. "Please verify with the client which of the following medications they are taking." B. "Please perform a complete assessment of the client." C. "Please document the admission assessment in the chart." D. "Please use these client assessment findings to draw a conclusion so that a plan can be developed."

Correct Answer is A

Explanation

A. This is an appropriate delegation to an LPN. It involves data collection, which is within the scope of LPN practice. The RN retains responsibility for medication administration and reconciliation.
B. This is inappropriate delegation. A complete assessment requires critical thinking and clinical judgment, which are within the scope of RN practice.
C. While documentation is important, it's usually the responsibility of the RN to ensure accurate and complete charting, especially for initial assessments.
D. Drawing conclusions and developing a plan requires nursing judgment and is the responsibility of the RN.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a class on professionalism. The nurse should include that which of the following is an example of accountability?

Correct Answer is B

Explanation

An RN on a behavioral health unit is assessing a client. The RN plans to delegate part of the nursing process to a licensed practical nurse (LPN). Which of the following statements by the RN indicates appropriate delegation to the LPN?

Correct Answer is A

Explanation

A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?

A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

A nurse administers the wrong medication to a client. After assessing the client, the nurse contacts the provider and completes an incident report. Which of the following components of professionalism is the nurse demonstrating?

A nurse is teaching a class about the transition from novice to expert nurse. The nurse should include that a nurse who requires support from a mentor is at which of the following stages?

A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?

A nurse is teaching a class about the transition from novice to expert nurse. The nurse should include that a nurse who is a preceptor to new staff members is at which of the following stages?

A nurse overhears two assistive personnel (APS) disagreeing about client care assignments. Which of the following actions by the nurse demonstrates conflict resolution?

A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

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.)