A nurse on the Cardiovascular unit is completing the patient's history and physical examination. Which of the following information provided by the patient should the nurse consider as subjective data?
Cyanosis.
Petechiae.
Dizziness.
Blood pressure.
The Correct Answer is C
Choice A rationale:
Cyanosis - Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. This is an objective sign that can be visually assessed, not based on the patient's description.
Choice B rationale:
Petechiae - Petechiae are small, pinpoint, red or purple spots on the skin caused by bleeding under the skin. Like cyanosis, this is a physical finding that can be observed directly.
Choice C rationale:
Dizziness - This is the correct choice. Dizziness is a subjective sensation that the patient experiences. It cannot be directly observed and relies on the patient's description of feeling unsteady, lightheaded, or having a spinning sensation.
Choice D rationale:
Blood pressure - Blood pressure is an objective measurement that can be taken using a blood pressure cuff and a stethoscope or automated device. It is not based on the patient's description and does not fall under subjective data.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
This choice is not correct because verifying the oxygen flow rate every other day is not part of the discharge teaching for a client on home oxygen therapy. The flow rate should be checked regularly, not just every other day, to ensure the client's safety and well-being.
Choice B rationale:
This choice is correct. Checking the tops of the ears for skin breakdown is important in a client using a nasal cannula for oxygen therapy. Prolonged use of the cannula can lead to irritation and pressure-related skin breakdown behind the ears.
Choice C rationale:
This choice is correct. Posting "no smoking signs in a prominent location in the home" is an important safety measure for a client on oxygen therapy. Oxygen supports combustion, and smoking in the presence of oxygen can lead to fire hazards.
Choice D rationale:
This choice is correct. Checking the cannula position on a regular basis is essential to ensure that the oxygen is being delivered effectively and that the client is not experiencing discomfort or skin breakdown due to improper positioning.
Choice E rationale:
This choice is correct. Applying petroleum ointment to the nares if they become dry and irritated is a suitable intervention to maintain the client's comfort and prevent skin irritation from the cannula.
Correct Answer is A
Explanation
Choice A rationale:
Instructing the client not to adjust the oxygen flow rate is crucial to ensure the appropriate amount of oxygen is delivered. Oxygen flow rates are prescribed by a healthcare provider based on the client's needs, and altering the flow rate without medical guidance can lead to inadequate oxygen delivery or oxygen toxicity.
Choice B rationale:
Weekly equipment checks are important, but this choice is not the most critical instruction. Clients should be instructed to check their oxygen equipment daily for proper functioning and to address any issues promptly. Waiting a whole week could lead to potential problems going unnoticed.
Choice C rationale:
Storing unused oxygen tanks horizontally is incorrect. Oxygen tanks should be stored upright to prevent leaks and ensure proper functioning. Storing them horizontally can cause valve damage and leakage, which could lead to hazards.
Choice D rationale:
Using wool blankets on the bed is not a suitable instruction for a client using oxygen therapy. Wool blankets can generate static electricity, which might pose a fire hazard in the presence of oxygen-enriched environments.
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