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 ["D","E"]

Explanation

A. If a client has just consumed ice water, it can lower the oral temperature and lead to inaccurate readings. It's generally recommended to wait at least 15-30 minutes after eating or drinking before taking an oral temperature.
B. A client who has had oral surgery may have swelling, pain, or open wounds, which could make taking an oral temperature uncomfortable and could also lead to inaccurate results. Alternative sites, such as axillary or tympanic, might be preferred.
C. Clients who primarily breathe through their mouth may have a lower oral temperature reading due to airflow affecting the measurement. Additionally, mouth breathing can lead to inaccuracies in the reading.
D. While hemorrhoids themselves do not affect the ability to take an oral temperature, this client is suitable for oral temperature measurement since it does not interfere with the method.
E. A client with a coagulation disorder can typically have their oral temperature taken. There are no contraindications to taking an oral temperature in this case, as long as the client does not have any other conditions affecting their ability to do so.

A. Systolic blood pressure B. Location of blood pressure cuff C. Unit of measurement D. Position of the client

Correct Answer is B

Explanation

A. The systolic blood pressure is clearly stated as "102 mm Hg" in the documentation. There is no need for clarification regarding the systolic value.
B. It is essential to document the site where the blood pressure was taken, as this can affect the accuracy of the reading. Typically, the blood pressure is measured in the brachial artery in the upper arm. If the cuff was placed on a different site, such as the wrist or ankle, this should be noted in the documentation.
C. The unit of measurement for blood pressure is correctly indicated as "mm Hg" (millimeters of mercury). There is no need for clarification regarding the unit since it is standard and clear.
D. The position of the client is correctly documented as sitting up in a chair.

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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 reinforcing teaching with a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg. client sitting up in a chair." Which of the following information should the nurse clarify?

Correct Answer is B

Explanation

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