Which of these assessment findings should a nurse record as subjective?
Hives.
Itching.
Vomiting.
Abdominal distension.
The Correct Answer is B
This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the
patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.
For example:
Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.
Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.
Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.
Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:
- Hives: No hives or rashes on the skin are normal.
- Vomiting: No vomiting or nausea are normal.
- Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The first observation the nurse should perform for a client who is receiving from the post anesthesia unit after a colon resection is to assess the patency of the airway and respiratory function.
This is because the airway is the most vital for the survival of the client and any compromise can lead to hypoxia and death.
The nurse should then take vital signs, check the wound dressing, and assess the foley catheter drainage.
Choice A is wrong because the client’s wound dressing is not as important as the airway and can be checked later.
Choice B is wrong because the client’s level of consciousness may be affected by the anesthesia and is not a priority over the airway.
Choice D is wrong because the client’s foley catheter drainage is not a critical observation and can be monitored later.
Normal ranges for respiratory rate are 12 to 20 breaths per minute for adults, oxygen saturation is 95% to 100%, and blood pressure is 120/80 mmHg for healthy individuals.
Correct Answer is B
Explanation
The nurse should hold and notify the prescriber because hydrochlorothiazide is a diuretic that can lower the serum potassium level. The client already has a high serum potassium level of 5.2 mmol/L, which is above the normal range of 3.5 to 5.0 mmol/L.
Giving hydrochlorothiazide could worsen the client’s condition and cause hypokalemia.
Choice A is wrong because metoprolol is a beta-blocker that can lower the blood pressure and heart rate.
The client’s blood pressure and heart rate are not given, so there is no reason to hold metoprolol based on the information provided.
Choice C is wrong because enoxaparin is an anticoagulant that can prevent blood clots. The client has a low platelet count of 98,000/mm, which is below the normal range of 150,000 to 450,000/mm.
However, this does not contraindicate the use of enoxaparin, unless the client has signs of bleeding or bruising.
Choice D is wrong because atorvastatin is a statin that can lower the serum cholesterol
level. The client has a high serum cholesterol level of 250 mg/dL, which is above the desirable level of less than 200 mg/dL.
Giving atorvastatin could help reduce the client’s risk of cardiovascular complications.
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