A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?

Temperature 38 C/100.4F, bowels sounds 15/minute

Nausea and stomach cramps.

Occasional cough, respiratory rate 18 breaths per minute

White blood cell count 14,000/mm3, pain 4/10

Answer and Explanation

The Correct Answer is B

A. Temperature and bowel sounds are measurable, making them objective data rather than subjective.

B. These symptoms cannot be measured or observed by the nurse; they are based on the patient's personal experience, making them subjective data.

C. While the cough is subjective, the respiratory rate is measurable and therefore objective. Since the option includes both types of data, it is not the best answer.

D. White blood cell count is objective. Pain rating is subjective, but since this option includes both types of data, it is not the best choice.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Teaching about medications. This is correct because providing education to a patient is a direct care intervention, as it involves interaction with the patient to improve their health outcomes.

B. Performing resuscitation. This is correct because resuscitation is a hands-on, immediate intervention aimed at stabilizing a patient, making it a direct care intervention.

C. Inserting a feeding tube. This is correct because placing a feeding tube is a direct intervention that involves a hands-on nursing procedure.

D. Documenting wound care. This is incorrect because documentation is an indirect care intervention. While it is essential for communication and continuity of care, it does not directly affect the patient's condition.

E. Ambulating a patient. This is correct because physically assisting a patient with walking is a direct care intervention that helps prevent complications such as deep vein thrombosis and pneumonia.

A. "Is this your first time experiencing these symptoms?" B. "Do you have any allergies?" C. "Can you describe what brought you to the hospital today?" D. "Are you feeling any pain right now?"

Correct Answer is C

Explanation

A. This is a closed-ended question that leads to a simple "yes" or "no" response, limiting the amount of information the nurse gathers.

B. While this is important information, it is not an appropriate opening question for a full nursing assessment, as it does not encourage the patient to share their primary concern.

C. This open-ended question allows the patient to provide a detailed narrative, helping the nurse gather a comprehensive history.

D. This is a closed-ended question that focuses only on pain rather than encouraging the patient to share their full reason for seeking care.

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A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?

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Naxlex Comprehensive Predictor Exams

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

Which of the following is the most appropriate open-ended question to begin a nursing assessment?

Correct Answer is C

Explanation

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A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?