Which step of the nursing process is being performed by the nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR)?

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.

Choice A reason: This is correct. Risk for injury related to smoking near supplemental oxygen is the priority nursing diagnosis for this family. Smoking near supplemental oxygen can cause a fire or an explosion that can injure or kill the patient and the spouse. The nurse should educate the family about the dangers of smoking near oxygen and provide resources to help the spouse quit smoking.

Choice B reason: This is incorrect. Risk-prone health behavior related to inability to quit smoking is a relevant nursing diagnosis for this family, but not the priority. Smoking is a harmful habit that can cause various health problems, such as lung cancer, heart disease, and stroke. The nurse should assess the spouse's readiness to quit smoking and provide support and counseling.

Choice C reason: This is incorrect. Ineffective health maintenance related to continued use of cigarettes is a valid nursing diagnosis for this family, but not the priority. Smoking can impair the health of the patient and the spouse, especially if the patient has a respiratory condition that requires supplemental oxygen. The nurse should monitor the patient's and the spouse's vital signs, oxygen saturation, and respiratory status.

Choice D reason: This is incorrect. Ineffective family therapeutic regimen management related to noncompliance is an appropriate nursing diagnosis for this family, but not the priority. Smoking near supplemental oxygen can indicate that the family is not following the prescribed treatment plan for the patient's condition. The nurse should evaluate the family's understanding of the patient's oxygen therapy and the reasons for noncompliance.