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 B

Explanation

A: Auscultation, or listening for air injected into the tube, is not a reliable method for verifying feeding tube placement. It can lead to false positives and does not confirm the tube’s location accurately.

B: X-ray is the gold standard for verifying feeding tube placement. It provides a clear image of the tube’s position, ensuring it is correctly placed in the stomach or small intestine, reducing the risk of complications.

C: Aspiration of contents can help verify placement by checking the appearance and pH of the aspirate. However, it is not as definitive as an X-ray and can sometimes be inconclusive.

D: pH testing of aspirate can indicate whether the tube is in the stomach (acidic pH) or intestines (less acidic). While useful, it is not as reliable as an X-ray for confirming placement.

A. Discreetly hide the medication in the patient’s favorite gelatin. B. Agree with the patient’s decision and document it in the chart. C. Explore with the patient reasons for not wanting to take the medication. D. Educate the patient about the importance of the medication.

Correct Answer is C

Explanation

A: Discreetly hiding the medication in the patient’s favorite gelatin is unethical and violates the patient’s right to informed consent. This approach undermines trust and can lead to further resistance or legal issues.

B: Agreeing with the patient’s decision and documenting it in the chart is important, but it should not be the first action. The nurse needs to understand the patient’s reasons for refusal before making any decisions or documentation.

C: Exploring with the patient the reasons for not wanting to take the medication is the appropriate first action. This approach allows the nurse to understand the patient’s concerns, address any misconceptions, and provide relevant information. It also respects the patient’s autonomy and promotes a collaborative approach to care.

D: Educating the patient about the importance of the medication is crucial, but it should follow the exploration of the patient’s reasons for refusal. Understanding the patient’s perspective first ensures that the education provided is relevant and addresses specific concerns.

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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 small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement?

Correct Answer is B

Explanation

A patient refuses medication. Which is the nurse’s first action?

Correct Answer is C

Explanation

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