A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)

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Pharmacology and the Nursing Process Test Bank Free Questions

Question 1 of 9

A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.

Question 2 of 9

The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?

Correct Answer: A

Rationale: The correct answer is A: Teaches proper handwashing technique. This is the most appropriate intervention because proper handwashing can help prevent the spread of infection, including urinary infections. Teaching the patient about handwashing empowers them to take control of their own hygiene, reducing the risk of infection. Summary of why other choices are incorrect: B: Properly cleans the patient's toilet - While important for maintaining cleanliness, this does not directly address the patient's risk for a urinary infection. C: Transports urine specimen to the lab - This is not a direct care intervention for preventing urinary infections. D: Informs the oncoming nurse during hand-off - Hand-off communication is important for continuity of care but does not directly address the patient's risk for a urinary infection.

Question 3 of 9

A male client is prescribed medications that depress thrombocytes. The nurse should monitor for which of the ff signs and symptoms in the client?

Correct Answer: C

Rationale: The correct answer is C: Bleeding gums and dark tarry stools. Thrombocytes are platelets responsible for blood clotting. Medications that depress thrombocytes can lead to decreased clotting ability, resulting in bleeding tendencies. Bleeding gums and dark tarry stools are common signs of bleeding due to decreased platelet function. A: Sore throat and swollen glands are more indicative of a possible infection or inflammation, not related to thrombocyte depression. B: Pernicious anemia with weakness is associated with vitamin B12 deficiency, not directly related to thrombocyte depression. D: Thickening of blood and bruising are not typical signs of decreased platelet function, but rather may be indicative of other conditions like clotting disorders.

Question 4 of 9

Which vein should be used first when initiating IV therapy?

Correct Answer: B

Rationale: The correct answer is B: Basilic vein. It is preferred for IV therapy due to its size, accessibility, and lower risk of complications. Basilic vein is deep and stable, aiding in successful catheter insertion and reduced risk of infiltration. Jugular vein (A) is not typically used due to the high risk of complications like infection. Brachiocephalic (C) and Axillary (D) veins are less commonly used as they are smaller and more prone to complications compared to the Basilic vein. In summary, the Basilic vein is the optimal choice for initiating IV therapy due to its size, accessibility, stability, and lower risk of complications.

Question 5 of 9

A client comes to the clinic complaining of weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. To assess possible causes for the fever, it would be most appropriate for the nurse to initially ask: a."Have you bee sexually active lately?" b, "Do you have a sore throat at the present time?"

Correct Answer: A

Rationale: Rationale: - The correct answer is A, "Have you been exposed recently to anyone with an infection?" because it helps assess potential sources of infection causing the low-grade fever and other symptoms. - Choice B is irrelevant as the client's current sore throat is not the main concern. - Choice C and D do not address the potential infectious etiology of the symptoms. - Overall, assessing recent exposure to infections is crucial in identifying possible sources of the client's symptoms.

Question 6 of 9

A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse’s priority when evaluating the patient?

Correct Answer: A

Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls. Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall. Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall. Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.

Question 7 of 9

Mr. Aurelio diagnosed with heart failure, was prescribed with a 2 gm sodium diet. which of the following foods would nurse Norma instruct him to restrict?

Correct Answer: B

Rationale: The correct answer is B: canned tomato juice. Canned tomato juice is high in sodium content, which would not be suitable for a patient on a 2 gm sodium diet for heart failure. Sodium restriction is crucial in managing heart failure to reduce fluid retention and strain on the heart. Whole wheat bread, beef tenderloin strips, and apples are lower in sodium content compared to canned tomato juice, making them more appropriate choices for someone on a low-sodium diet.

Question 8 of 9

A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.

Question 9 of 9

What is the primary purpose of using measurable client outcomes during the nursing process?

Correct Answer: B

Rationale: The primary purpose of using measurable client outcomes during the nursing process is to evaluate the effectiveness of nursing interventions. This is crucial in determining whether the care provided has led to the desired outcomes for the client's health. By measuring outcomes, nurses can assess if the interventions are successful, make any necessary adjustments to the care plan, and ensure optimal patient outcomes. Choice A is incorrect because diagnosing client conditions accurately is not the primary purpose of using measurable client outcomes; it is more related to the initial assessment phase. Choice C is incorrect because prioritizing nursing diagnoses effectively is an important aspect of the nursing process, but it is not the primary purpose of using measurable client outcomes. Choice D is incorrect because while documentation in the client's health record is important, it is not the primary purpose of using measurable client outcomes.

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