A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?

Petechiae

Blood pressure

Nausea

Cyanosis

Answer and Explanation

The Correct Answer is C

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.

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Correct Answer is A

Explanation

A: Having another nurse witness the wasted medication is the correct procedure. This ensures accountability and compliance with regulations regarding the handling and disposal of controlled substances.

B: Returning the wasted medication to the medication dispenser is not appropriate. Once a narcotic has been withdrawn, it cannot be returned to the dispenser due to contamination and safety protocols.

C: Placing the wasted portion of the medication in the sharps container is not correct. Narcotics should be disposed of according to specific protocols, which typically involve witnessing and documentation, not simply placing them in a sharps container.

D: Exiting the medication room to call the health care provider to request an order that matches the dosages is unnecessary. The nurse should follow the proper procedure for wasting the medication with a witness.

A. Lower the head of the client’s bed. B. Check the client’s gag reflex. C. Remove the client’s peripheral IV. D. Check the client for bladder distention.

Correct Answer is B

Explanation

A: Lowering the head of the client’s bed is not appropriate in this situation. It does not address the safety concern related to swallowing.

B: Checking the client’s gag reflex is the correct action. This ensures that the client can safely swallow ice chips without the risk of aspiration.

C: Removing the client’s peripheral IV is not related to the request for ice chips and is unnecessary unless there is a specific reason to do so.

D: Checking the client for bladder distention is not relevant to the request for ice chips and does not address the immediate concern of safe swallowing.

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A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has withdrawn a narcotic from the medication dispenser and must waste a portion of the medication. What should the nurse do?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative and has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a 75-year-old client with aspiration pneumonia. The nurse should recognize what age-related change can contribute to the development of aspiration pneumonia?

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize which assessment is the priority?

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The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea?

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

A nurse is measuring a client’s oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

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