A nurse is conducting a patient’s history and physical examination. Which information should the nurse consider as subjective data?
Petechiae
Nausea
Cyanosis
Fever
The Correct Answer is B
Choice A rationale
Petechiae, or small red or purple spots on the skin caused by minor bleeding from broken capillary blood vessels, are an objective finding. They can be seen and evaluated by the nurse during a physical examination.
Choice B rationale
Nausea is a subjective symptom. It is something the patient experiences and reports, but it cannot be directly observed or measured by the nurse.
Choice C rationale
Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective finding. It can be observed by the nurse during a physical examination.
Choice D rationale
Fever is an objective finding. It can be measured by the nurse using a thermometer.
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Before administering digoxin, it is crucial to measure the patient’s apical pulse. Digoxin affects the heart rate, and a low pulse could indicate that the dose needs to be adjusted.
Choice B rationale
Offering a light snack is not specifically required before administering digoxin.
Choice C rationale
While it’s always important to monitor a patient’s blood pressure, it’s not specifically required before administering digoxin.
Choice D rationale
Weighing the patient is not specifically required before administering digoxin.
Correct Answer is A
Explanation
Choice A rationale
The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.
Choice B rationale
Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.
Choice C rationale
Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.
Choice D rationale
Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.
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