A nurse is collecting data from a client who is postoperative. Which of the following findings should the nurse identify as objective data?(Select All that Apply.)
The client is reporting nausea.
The client's urine output has been 150 mL over the past 3 hr.
The client states they are experiencing "extreme pain".
The client's current blood pressure is below their preoperative reading.
The client's right calf is swollen and warm to the touch.
Correct Answer : B,D,E
A. It reflects the client’s personal feelings and experiences regarding their condition. Since it is based on
the client's report rather than measurable findings, it does not qualify as objective data.
B. It provides measurable information about the client's urine output, which can be quantified and observed by the nurse. Objective data is factual and can be verified by anyone observing the situation.
C. Like the nausea report, this statement is based on the client’s personal experience and perception of
pain. It cannot be measured objectively, making it subjective.
D. Blood pressure readings are measurable and can be objectively compared to preoperative values. This information provides concrete data regarding the client's current condition.
E. The observations of swelling and warmth can be directly assessed and are factual findings that can be confirmed by the nurse during the physical examination.
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Related Questions
Correct Answer is D
Explanation
A. This task should not be delegated to an AP. Administering medication, especially pain medication, requires nursing assessment and judgment, including monitoring for effectiveness and potential side effects. Only licensed nurses can administer medications.
B. This task is also not suitable for delegation to an AP. Wound care, particularly for a pressure injury, requires specialized knowledge and skills to assess the wound, determine appropriate care, and evaluate for signs of infection. This should be performed by a licensed nurse.
C. This task involves patient education and reinforcement of nursing instructions, which should be conducted by a nurse. While an AP can assist with the use of the incentive spirometer, the initial teaching and reinforcement should be handled by a licensed nurse.
D. This task is appropriate for delegation to an AP. Obtaining a daily weight is a routine task that does not require nursing judgment or assessment beyond standard procedure. The AP can report the weight to the nurse, who will then assess any necessary interventions based on the results.
Correct Answer is A
Explanation
A. The behavior of sunbathing can be changed or managed to reduce the risk of skin cancer and other related conditions. Individuals can choose to limit sun exposure, use sunscreen, or wear protective clothing.
B. This is a non-modifiable risk factor. Genetic predisposition to certain diseases cannot be changed, as it is determined by one's DNA and family heritage.
C. This is also a non-modifiable risk factor. Age is a natural and unavoidable factor that influences the risk of developing various diseases, as the risk typically increases with advancing age.
D. This is a non-modifiable risk factor as well. A family history of certain diseases indicates a genetic predisposition, which cannot be altered.
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