A nurse is documenting the data collected from an assessment of a client who has a urinary tract infection (UTI). Which of the following statements should the nurse use to record objective data?

Choice A reason:

The size and depth of the ulcer are important indicators of the severity and healing progress of the wound. The nurse should measure the length, width, and depth of the ulcer using a ruler or a probe and document the findings. The nurse should also note the presence of any undermining or tunneling in the wound bed.

Choice B reason:

The presence of drainage or odor can signal infection or necrosis in the wound. The nurse should assess the amount, color, consistency, and odor of the drainage and document the findings. The nurse should also culture the wound if indicated and initiate appropriate wound care interventions.

Choice C reason:

The type and amount of pain medication administered are not directly related to the assessment of the pressure ulcer. Pain is a subjective experience that varies among individuals and situations. The nurse should assess the client's pain level using a valid pain scale and administer analgesics as prescribed, but this is not part of the ongoing assessment of the wound itself.

Choice D reason:

The client's nutritional status and intake are vital factors that affect wound healing. The nurse should assess the client's weight, body mass index, serum albumin, prealbumin, and transferrin levels, and dietary intake of protein, calories, vitamins, minerals, and fluids. The nurse should also provide nutritional supplements or consult a dietitian as needed to optimize the client's nutritional status.

Choice E reason:

The client's level of mobility and activity are also important factors that influence wound healing. The nurse should assess the client's ability to move, reposition, and ambulate independently or with assistance. The nurse should also implement measures to reduce pressure, shear, and friction on the wound site, such as using pressure-relieving devices, turning and repositioning the client frequently, and providing skin care.

Choice A reason:

The client states that he has trouble sleeping at night. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice B reason:

The client has a blood pressure of 150/90 mm Hg. This is objective data because it is information that the nurse observes when conducting a physical assessment. Objective data is measurable and observable.

Choice C reason:

The client reports feeling anxious about his diagnosis. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice D reason:

The client prefers not to discuss his personal issues. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.