A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking.
The nurse should identify that the client has manifestations of which of the following complications?

Choice A rationale:

In the SOAP charting model, the subjective component is where the client's subjective information and feelings are documented. This includes the client's own reports of symptoms, sensations, and experiences. In this case, the client reporting chest pain after mowing the lawn this morning is a subjective statement made by the client. This information is valuable as it provides insight into the client's perception of their condition and helps healthcare providers understand their symptoms and experiences.

Choice B rationale:

The blood pressure reading (182/98 mm Hg) is an objective measurement, not a subjective statement from the client. Objective data includes measurable and observable information, like vital signs, lab results, and physical examination findings. This type of information is typically documented in the objective component of SOAP charting.

Choice C rationale:

The administration of nitroglycerin (0.3 mg SL) is also an objective action taken by the client, not a subjective statement. It falls under the plan section of the SOAP chart, where healthcare providers outline the actions or interventions taken.

Choice D rationale:

The description of the client's skin (pale and diaphoretic) is also objective data. It represents observable physical signs and is not part of the subjective component, which focuses on the client's own statements and feelings.

Choice A rationale:
Quality of practice involves the nurse's competence in providing care to patients and ensuring that the care meets established standards. Violating the quality of practice standard would typically involve issues related to the quality and safety of care provided. In this scenario, the nurse's violation is related to accessing a client's medical record without being involved in their care, which is an ethical breach rather than a violation of the quality of practice standard.
Choice B rationale:
Code of ethics is the standard of professional performance that the nurse is violating. Accessing a client's medical record without being involved in their care is a violation of the ethical principles outlined in the Code of Ethics for Nurses. This action breaches patient confidentiality and privacy, which are fundamental ethical obligations for nurses.
Choice C rationale:
Collaboration involves working effectively with other healthcare professionals to provide optimal patient care. Violations of the collaboration standard would typically involve issues related to teamwork, communication, and interdisciplinary relationships. The scenario described does not pertain to collaboration but rather concerns ethical conduct.
Choice D rationale:
Evidence-based practice refers to the integration of current research evidence into clinical decision-making and patient care. Violations of evidence-based practice would involve not following the latest research and best practices in patient care. In this case, the nurse's violation is related to ethical principles and patient privacy rather than evidence-based practice.