Assessment Data: The patient's incision is clean, dry, and intact with staples.
A nurse is collecting data during the assessment of a patient.
During the assessment, the nurse collects both subjective and objective data.
Determine which data is subjective.
The patient refused breakfast after vomiting 200 mL green emesis.
The patient reports having sharp, burning pain with urination.
The patient's catheter drained 400 mL of urine during the last 8 hours.
The patient complains of extreme nausea upon awakening.
The patient refused breakfast after vomiting 200 mL green emesis.
The patient reports having sharp, burning pain with urination.
The patient's catheter drained 400 mL of urine during the last 8 hours.
The patient complains of extreme nausea upon awakening.
Correct Answer : B,D
Choice A rationale
"The patient refused breakfast after vomiting 200 mL green emesis" is objective data. Vomiting and the amount and color of emesis are observable and measurable facts that can be directly assessed by the nurse.
Choice B rationale
"The patient reports having sharp, burning pain with urination" is subjective data. Pain is a symptom experienced and described by the patient; it cannot be objectively measured or directly observed by the nurse. The description of the pain (sharp, burning) is the patient's personal perception.
Choice C rationale
"The patient's catheter drained 400 mL of urine during the last 8 hours" is objective data. The amount of urine output via a catheter is a measurable quantity that the nurse can directly observe and record.
Choice D rationale
"The patient complains of extreme nausea upon awakening" is subjective data. Nausea is a feeling reported by the patient and is a subjective experience. The intensity ("extreme") is also based on the patient's personal perception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
To convert 12: am to military time, for any time between 12: am and 12: am, the 12 is replaced with 00. Therefore, 12: am becomes 0018 in military time.
Choice B rationale
2418 is not a valid representation of time in either standard or military format. Military time ranges from 0000 to 2359.
Choice C rationale
1218 in military time represents 12: pm in standard time, not 12: am. In the afternoon and evening, 12 is added to the standard hour to convert to military time (e.g., 1 pm is 1300).
Choice D rationale
0118 in military time represents 1: am in standard time. The hour remains the same for times between 1: am and 9: am, with a leading zero added to the hour. .
Correct Answer is C
Explanation
Choice A rationale
Information about the family of a client in a different room (room 107) is not directly relevant to the change-of-shift report for the client in room 108. The report should focus on information pertinent to the care of the assigned client.
Choice B rationale
While the fact that a client in room 105 had a bath might be included in their specific report, it is not essential information to communicate during the change-of-shift report for the client in room 108 who has a new pain medication.
Choice C rationale
The administration of a new pain medication to the client in room 108 is crucial information for the oncoming nurse. It is essential to communicate the name of the medication, the time it was given, the dosage, the route of administration, and the client's response to the medication to ensure continuity of pain management.
Choice D rationale
The dietary preferences of a client in a different room (room 109) are not relevant to the change-of-shift report for the client in room 108. Dietary information is specific to each client and should be communicated within their individual report if pertinent to their current care.
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