Which data will the nurse categorize as objective for a patient who has just completed an assessment?

The patient’s lung sounds are diminished bilaterally with expiratory wheezes.

The patient worries that the insurance company will not pay the hospital bill.

The patient wonders if supplemental oxygen at home would be beneficial.

The patient felt less short of breath after receiving a nebulizer treatment.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct choice because the patient’s lung sounds are diminished bilaterally with expiratory wheezes is an example of objective data. Objective data is observable and measurable information that can be verified by the nurse or other health care professionals. The nurse can use a stethoscope to listen to the patient’s lung sounds and document the findings.

Choice B reason: This is an incorrect choice because the patient worries that the insurance company will not pay the hospital bill is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s worry, but can only rely on the patient’s verbal report.

Choice C reason: This is an incorrect choice because the patient wonders if supplemental oxygen at home would be beneficial is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s wonder, but can only rely on the patient’s verbal report.

Choice D reason: This is an incorrect choice because the patient felt less short of breath after receiving a nebulizer treatment is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s feeling, but can only rely on the patient’s verbal report.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because temperature, pulse, and blood pressure are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and pulse and blood pressure can be affected by other factors, such as anxiety or medication.

Choice B reason: This is the correct choice because pulse, respirations, and oxygen saturation are the most important vital signs for a patient who is experiencing shortness of breath. Pulse reflects the heart rate and rhythm, which can be altered by respiratory distress. Respirations reflect the rate and depth of breathing, which can indicate the severity of the condition. Oxygen saturation reflects the percentage of hemoglobin that is bound with oxygen, which can indicate the adequacy of oxygenation.

Choice C reason: This is an incorrect choice because temperature, pulse, and respirations are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and respirations alone do not provide enough information about the oxygenation status of the patient.

Choice D reason: This is an incorrect choice because respirations, blood pressure, and pain are not the most important vital signs for a patient who is experiencing shortness of breath. Blood pressure can be affected by other factors, such as anxiety or medication, and pain is a subjective symptom that can vary from person to person. Oxygen saturation is a more objective and reliable indicator of oxygenation than pain.

A. Making sure that the earpieces fit loosely in the nurse’s ear canals B. Utilizing a stethoscope with the longest possible tubing C. Placing the diaphragm firmly against the patient’s skin D. Positioning the bell very lightly over the patient’s sternum

Correct Answer is C

Explanation

Choice A reason: This is incorrect. Making sure that the earpieces fit loosely in the nurse’s ear canals will not help the nurse hear the heartbeat more clearly. Loose earpieces can let in ambient noise and reduce the sound quality.

Choice B reason: This is incorrect. Utilizing a stethoscope with the longest possible tubing will not help the nurse hear the heartbeat more clearly. Long tubing can reduce the sound transmission and create interference.

Choice C reason: This is correct. Placing the diaphragm firmly against the patient’s skin will help the nurse hear the heartbeat more clearly. The diaphragm is the flat circular part of the chest piece that is used to listen to low-pitched sounds, such as the heart. Firm pressure creates a good seal and blocks out external noise.

Choice D reason: This is incorrect. Positioning the bell very lightly over the patient’s sternum will not help the nurse hear the heartbeat more clearly. The bell is the small cup-shaped part of the chest piece that is used to listen to high-pitched sounds, such as the lungs. Light pressure is needed to avoid activating the diaphragm, but the sternum is not the best location to listen to the apical pulse.

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Which data will the nurse categorize as objective for a patient who has just completed an assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which vital signs are most important for a patient who is experiencing shortness of breath?

Correct Answer is B

Explanation

The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?

Correct Answer is C

Explanation

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