Exhibits

Review the electronic health record. Which finding(s) should the nurse identify as subjective data? Select all that apply.

A. The client states, "My headache is an 8 out of 10 and throbbing.": This is subjective data because it reflects the client’s personal perception and experience of pain, which cannot be measured or observed by the nurse.

B. The client verbalizes, "I have a headache because I have not slept.": This is also subjective data as it represents the client’s opinion about the cause of their headache rather than observable facts.

C. The caregiver expresses concern about their infant crying all night: This is subjective information reported by the caregiver. It provides insight into the caregiver’s perspective but is not directly measurable or observed by the nurse.

D. The client exhibits facial grimacing and guards a swollen right forearm: This is objective data because it is observable and measurable behavior noted by the nurse. These physical signs can be verified independently of the client’s report.

Safe:
• A nurse cleans their stethoscope before auscultating the client's lungs
• A nurse raises the bed to waist level when completing a physical assessment
• An unlicensed assistive personnel (UAP) helps a client with a steady gait use a cane to ambulate down the hall
• The nurse covers their mouth and nose with their upper arm and elbow during a sneeze

Unsafe:
• A nurse administers medication to a client despite the name on the ID band not matching what the client said
• A client's family lowers all of the side rails on the bed of a client who is on fall precautions

Rationale

• A nurse cleans their stethoscope before auscultating the client's lungs: Cleaning the stethoscope reduces the risk of transmitting pathogens between clients, promoting infection control. This is a standard safe practice in clinical care.

• A nurse raises the bed to waist level when completing a physical assessment: Raising the bed to waist level allows the nurse to maintain proper body mechanics and reduce risk of musculoskeletal injury. This is consistent with safe patient handling protocols.

• An unlicensed assistive personnel (UAP) helps a client with a steady gait use a cane to ambulate down the hall: Assisting a client who is stable and using a mobility aid is safe, as long as the UAP follows proper techniques and ensures the client’s stability during ambulation.

• The nurse covers their mouth and nose with their upper arm and elbow during a sneeze: Using the elbow or upper arm to cover a sneeze prevents the spread of respiratory droplets, reducing infection risk. This is recommended over using hands, which can contaminate surfaces.

• A nurse administers medication to a client despite the name on the ID band not matching what the client said: Administering medication without verifying the correct identity violates the “right patient” safety protocol. This can result in medication errors and harm, making it unsafe.

• A client's family lowers all of the side rails on the bed of a client who is on fall precautions: Lowering side rails for a patient at fall risk increases the likelihood of injury from falls. Side rails should be maintained according to the patient’s safety plan, making this action unsafe.