A nurse is completing a client’s assessment.
Which of the following should the nurse consider as objective data?

Choice A rationale
Planning involves setting goals and determining the appropriate interventions to achieve those goals. It is not the step being performed when changing a wound dressing.
Choice B rationale
Evaluation involves assessing the effectiveness of the interventions and determining if the goals have been met. It is not the step being performed when changing a wound dressing.
Choice C rationale
Assessment involves gathering data about the client’s condition. While assessment is an ongoing process, it is not the primary step being performed when changing a wound dressing.
Choice D rationale
Implementation involves carrying out the planned interventions. Changing a wound dressing is an example of implementing a nursing intervention.

Choice A rationale
Ignoring the comment and documenting “No Known Allergies” (NKA) is incorrect because it disregards the client’s report of an allergy. This action could lead to potential harm if the client is indeed allergic to codeine.
Choice B rationale
Asking the client why they think it is an allergy is not the best response. It may come across as dismissive and does not provide the nurse with specific information about the client’s allergic reaction.
Choice C rationale
Telling the client not to worry and that they will be okay if they take codeine with food is incorrect. This response is dismissive of the client’s concern and does not address the potential for an allergic reaction.
Choice D rationale
Asking the client what symptoms they experience with codeine is the best response. It allows the nurse to gather specific information about the client’s allergic reaction, which is crucial for safe medication administration.