A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data?

(Select All that Apply.)

Client reports dull, aching pain in lower right calf.

Client reports nausea following administration of pain medication.

Client's oral temperature is 38.4° C (101.2° F).

Client reports the rash on their back is itchy.

Client has a vesicular rash on their upper back.

Answer and Explanation

Correct Answer : A,B,D

A.   This is subjective data. The description of pain as "dull" and "aching" is based on the client's personal experience and cannot be measured directly by the nurse. Pain is a subjective symptom because it varies from person to person and is reported by the patient.
B.   This is subjective data. Nausea is a feeling or sensation reported by the client and is based on their personal experience. The nurse relies on the client's report to assess this symptom, as it cannot be directly observed or measured.
C.   This is objective data. The temperature reading is a measurable, quantifiable fact that can be directly observed and recorded by the nurse using a thermometer. It provides concrete evidence of the client's condition.
D.   This is subjective data. Itchiness is a sensation reported by the client and is based on their personal experience. The nurse cannot measure itchiness directly; they rely on the client’s description to understand the symptom.
E.   This is objective data. The presence of a vesicular rash is an observable finding that the nurse can see and document. It is a physical characteristic that can be directly assessed and recorded.

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Correct Answer is A

Explanation

A. This client needs IV pain medication, which requires advanced skills and knowledge to manage and administer safely. This situation involves complex and sensitive care, including pain management and end-of-life issues. RNs are typically responsible for administering IV medications, especially in critical or end-of-life situations.
B. A client who is 3 days postoperative and needs a dressing change generally requires a level of care that may be suitable for LPNs. LPNs are trained to perform dressing changes and manage postoperative wounds. However, if there are complications or concerns about the wound or the client’s condition, the RN should oversee or handle the situation.
C. Frequent ambulation can be managed by assistive personnel (AP) under the supervision of the RN. This task typically involves supporting and assisting the client with walking, which is within the scope of AP duties. LPNs can also assist with ambulation, but it is generally a task appropriate for APs when performed as part of routine care.
D. A client in protective isolation requires careful attention to infection control practices to protect them from infections. While the RN is responsible for ensuring adherence to isolation protocols and assessing the client’s needs, the day-to-day care tasks might be managed by LPNs and APs, provided they are trained in infection control procedures.

A. Assessment B. Evaluation C. implementation D. Planning

Correct Answer is D

Explanation

A. Assessment involves collecting and analyzing data about the client's health status, including their medical history, physical examination findings, and any other relevant information. This step is crucial for understanding the client's current condition and needs, but it precedes goal setting.
B. Evaluation is the step where the nurse determines whether the goals and outcomes established in the planning phase have been achieved. It involves assessing the effectiveness of interventions and making adjustments as needed. Evaluation occurs after goals have been set and interventions have been implemented, so it is not the step where goals are initially formulated.
C. Implementation involves carrying out the interventions and actions planned to achieve the goals established for the client. This step follows the formulation of goals and involves executing the planned care. While critical to achieving positive outcomes, implementation does not include the initial formulation of goals.
D. Planning is the step of the nursing process where the nurse formulates goals and develops a plan of care based on the assessment data. This includes setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided and achieve positive client outcomes. Planning is where goals are established to address the client’s identified needs and guide subsequent interventions.

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A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

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A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data?

(Select All that Apply.)