A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

The patient has low blood pressure.

The patient is short of breath.

The patient has wound drainage.

The patient reports feelings of fatigue.

Answer and Explanation

The Correct Answer is D

A: Low blood pressure is an objective finding that can be measured directly.

B: Shortness of breath is a subjective symptom reported by the patient.
C: Wound drainage is an objective finding that can be observed directly.

D: Feelings of fatigue are subjective symptoms reported by the patient, reflecting their personal experience rather than directly observable physical signs.

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Correct Answer is A

Explanation

A: Applying pressure over a bony prominence helps assess for pitting edema, a common indicator of fluid retention causing swelling. This action provides objective data to confirm the patient's subjective observation.
B: Percussion is not typically used to assess edema. It is more suitable for assessing the density of underlying structures.
C: Elevating the feet may help alleviate swelling but does not confirm the presence of edema.
D: Documenting the observation is important, but further assessment is needed to confirm the patient's concern.

A. A sonorous wheeze upon inspiration. B. Musical or whistling sounds with respirations. C. Noisy, snoring sounds during respirations. D. Sounding like hair being rubbed between the thumb and index fingers.

Correct Answer is D

Explanation

A: Sonorous wheezes are low-pitched sounds and do not describe fine rales.

B: Musical or whistling sounds typically describe wheezes which are continuous and not the discontinuous sound of rales.
C: Noisy, snoring sounds are characteristic of rhonchi, not rales.

D: Fine rales are high-pitched, brief, and discontinuous crackling sounds that are often likened to the sound of hair being rubbed between fingers, indicative of fluid in the small airways.

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A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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