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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The planning step involves setting goals and determining appropriate interventions to achieve desired outcomes for the client. During this phase, the nurse collaborates with the healthcare team, including
the RN, to establish measurable and realistic goals tailored to the client’s needs.
B. This step refers to the execution of the planned interventions. It involves carrying out the nursing actions and strategies that were developed during the planning phase. While important, implementation is not the stage where goals are formulated.
C. Evaluation is the step where the nurse assesses the effectiveness of the interventions and whether the goals have been met. This phase involves reviewing the client’s progress and determining if adjustments are needed for the care plan. Formulating goals occurs prior to this step.
D. This step is part of the assessment phase, where the nurse gathers information about the client’s health status, history, and needs. While data collection is essential for informing the planning process, it does not involve the formulation of goals.
Correct Answer is ["A","B","F"]
Explanation
A. This is indeed a fundamental aspect of nursing as per the ANA's definition. Nurses work to protect and promote health for their clients.
B. This statement accurately reflects the ANA's emphasis on the nursing process as a systematic approach to delivering care.
C. This does not align directly with the ANA's definition, which focuses more on the roles and responsibilities of nurses rather than assisting others in decision-making.
D. While knowledge of laws and regulations is essential for nurses, the ANA's definition does not state that nursing involves providing these laws.
E. While this is important in nursing, the ANA's definition specifically emphasizes protecting and promoting health rather than solely focusing on avoidance.
F. Advocacy is a key component of nursing practice and is explicitly recognized in the ANA's definition.
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