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?
The client states that they have a burning sensation when urinating.
The client has a temperature of 38.2°C (100.8°F) and a pulse of 110/min.
The client appears restless and anxious during the examination.
The client reports drinking cranberry juice to prevent UTIs.
The Correct Answer is B
Choice A reason:
This statement is not objective data because it is based on what the client states, not what the nurse observes or measures. This is an example of subjective data, which is information that depends on personal feelings.
Choice B reason:
This statement is objective data because it is based on what the nurse observes or measures using a thermometer and a pulse oximeter. This is an example of objective data, which is information that is factual and can be verified.
Choice C reason:
This statement is not objective data because it is based on the nurse's interpretation of the client's appearance and behavior, not on direct observation or measurement. This is an example of subjective data, which is information that represents the patient's perceptions, feelings, or concerns.
Choice D reason:
This statement is not objective data because it is based on what the client reports, not what the nurse observes or measures. This is an example of subjective data, which is information that the patient tells the nurse that cannot be measured or observed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The nurse uses a mechanical lift to transfer the client from bed to chair. This is the correct answer because it demonstrates the use of appropriate resources and equipment to prevent injury to the client and the nurse, and to facilitate safe mobility for the client who has impaired mobility due to a stroke. A mechanical lift is a device that helps lift and move a person who cannot move on their own or with minimal assistance.
Choice B reason:
The nurse performs passive range of motion exercises for the affected limbs. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps maintain joint mobility, prevent contractures, and improve circulation for the client who has impaired mobility due to a stroke. Passive range of motion exercises are movements that are done by someone else for a person who cannot move their own limbs.
Choice C reason:.
The nurse encourages the client to participate in physical therapy sessions. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps promote recovery, prevent complications, and improve function for the client who has impaired mobility due to a stroke. Physical therapy is a type of rehabilitation that involves exercises and activities that help improve strength, balance, coordination, and mobility.
Choice D reason:
The nurse applies antiembolic stockings and sequential compression devices to the lower extremities. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps prevent deep vein thrombosis (DVT), a potential complication of stroke that occurs when a blood clot forms in a vein deep in the body. Antiembolic stockings are tight-fitting elastic socks that apply pressure to the legs and feet to improve blood flow and prevent clotting. Sequential compression devices are inflatable sleeves that wrap around the legs and inflate and deflate periodically to squeeze the veins and improve blood flow.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason:
Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.
Choice B reason:
Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.
Choice C reason:
Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.
Choice D reason:
Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.
Choice E reason:
Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.
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