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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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 C
Explanation
A. While important for health, this choice is more about healthcare access rather than the social and community context that affects health outcomes.
B. This relates to educational resources but is not a primary example of the social context affecting health directly.
C. Access to transportation affects a person's ability to reach healthcare services, social support, and community resources. It plays a significant role in social interactions and overall well-being, highlighting how transportation availability impacts health outcomes within the community context.
D. While relevant to community health and encouraging physical activity, it focuses more on environmental factors rather than directly addressing social context.
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