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

Client reports the rash on their back is itchy

Client reports nausea following administration of pain medication.

Client has a raised, red rash on their upper back.

Client reports dull, aching pain in lower right calf.

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

Answer and Explanation

Correct Answer : A,B,D

A.   This entry reflects the client’s personal experience and perception of the rash. It is not measurable and relies on the client’s description.

B.   This statement is also based on the client’s experience and feelings about their condition after taking medication. It is a personal report and not an observable finding.
C.   This is an observation made by the nurse. The description of the rash is measurable and can be documented as a physical finding.
D.   Similar to options A and B, this entry describes the client’s perception of pain. It is a personal
experience that cannot be directly measured.
E.   This is a measurable finding obtained through a thermometer. It provides concrete evidence of the
client’s condition and does not rely on the client’s report.

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Correct Answer is C

Explanation

A. During this time, the person may be infected but does not exhibit any symptoms. Since the client is already experiencing symptoms (sneezing, productive cough, muscle aches, headache, and fever), they are not in the incubation stage.
B. This stage occurs after the acute phase of an infection when the symptoms begin to subside, and the individual starts to recover. The client is still exhibiting significant symptoms, so this stage does not apply.
C. This is the stage of an infection where the individual experiences the most severe symptoms. The
client’s symptoms, including sneezing, cough, muscle aches, headache, and fever, indicate that they are
likely in this stage, as these signs point to a full-blown illness.
D. The prodromal stage is the period following the incubation stage, where the first signs and symptoms appear but are not yet specific or severe. Symptoms can be vague and may include mild aches or fatigue. Since the client is presenting with significant symptoms, they are beyond the prodromal stage.

A. "An example of a sentinel event is administering client medications 30 minutes late." B. "An example of a sentinel event is documenting vital signs at the wrong time in the client's electronic health record." C. "An example of a sentinel event is administering a prescribed sedative to a client for insomnia." D. "An example of a sentinel event is administering incompatible blood products to a client."

Correct Answer is D

Explanation

A. While administering medications late can lead to adverse effects, it is not classified as a sentinel event unless it results in significant harm or adverse outcomes. This statement does not accurately reflect the definition of a sentinel event.
B. Documenting vital signs incorrectly can contribute to medical errors, but it does not qualify as a sentinel event on its own unless it leads to serious injury or death. Therefore, this statement does not demonstrate an accurate understanding of sentinel events.
C. Administering a prescribed medication, such as a sedative for insomnia, is part of standard nursing practice, assuming it is done correctly and appropriately. This does not represent a sentinel event unless there is a severe adverse outcome resulting from the administration. Thus, this statement is incorrect.
D. This statement accurately describes a sentinel event. Administering incompatible blood products can lead to severe, life-threatening complications, including hemolytic reactions, and is a clear example of a sentinel event requiring immediate investigation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports sneezing, productive cough, muscle aches, headache, and fever that has progressed over the last 4 days. Which of the following stages of infection is the client likely experiencing?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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