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 B
Explanation
thoroughly. The patient may not have verbalized pain but could still be experiencing it.
B. The patient states, "It feels like a knife stabbing me.": This documents subjective data verbatim using the patient’s exact words, which is best practice for accuracy and clarity.
C. "Lump diminished.": This lacks specificity—the exact size, texture, or other changes should be documented using precise measurements (e.g., “Lump decreased from 3 cm to 2 cm”).
D. "Patient's condition much better today than yesterday.": This is too vague and lacks measurable indicators of improvement (e.g., vital signs, pain level, mobility).
Correct Answer is D
Explanation
A. Oxygen will be continued: Continuing oxygen therapy is an intervention, not a measurable outcome.
B. The patient's coughing frequency will increase: While coughing can help clear secretions, increased coughing does not necessarily indicate improved airway clearance.
C. Cyanosis may be present: Cyanosis is a sign of worsening oxygenation, not an improved outcome.
D. Within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea: A desired outcome should be specific, measurable, and indicate improvement. The resolution of dyspnea demonstrates effective airway clearance.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.