The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)
Assistive personnel reports the patient walks with a limp
Patient reports pain level as 3 on a scale of 1 to 10
Heart rate 72 beats per minute
Respiratory rate 22 per minute with even unlabored respirations
Coughed up 5 mL yellow sputum
Headache in frontal area
Correct Answer : C,D,E
A. Assistive personnel reports the patient walks with a limp: This is secondhand information (reported by UAP), not directly observed by the nurse.
B. Patient reports pain level as 3 on a scale of 1 to 10: Pain is subjective data because it is based on the patient's self-report.
C. Heart rate 72 beats per minute: Heart rate is measured by the nurse, making it objective data.
D. Respiratory rate 22 per minute with even unlabored respirations: The nurse directly observes and measures respiratory rate, making it objective data.
E. Coughed up 5 mL yellow sputum: The nurse can observe and quantify the sputum (color and volume), making it objective data.
F. Headache in frontal area: A headache is subjective data because only the patient can describe it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Confidentiality: The biggest concern is maintaining patient confidentiality due to risks of unauthorized access, hacking, and breaches of protected health information (PHI).
B. Adequate forms for documentation: Computerized charting typically has structured templates, ensuring that all necessary fields are included.
C. Incorrect information: While errors can occur, computerized charting often includes safeguards like drop-down menus, alerts, and validation checks to reduce mistakes.
D. None of the answers are correct: Confidentiality is a significant concern, making option A the best answer.
Correct Answer is B
Explanation
A. Block: Block charting documents everything over a set period (e.g., entire shift), rather than only changes.
B. By exception: Charting by exception (CBE) means only documenting significant changes in condition or treatment rather than routine care.
C. Focused: Focused charting documents care related to a specific problem, not just exceptions.
D. SOAP: SOAP (Subject
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