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

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Question 1 of 5

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, such as their feelings, perceptions, and symptoms. In this case, the patient describing excitement about discharge is subjective as it is based on their personal experience. The other options (A, B, D) are objective data as they can be measured or observed directly without interpretation. The patient's temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. Therefore, only choice C fits the definition of subjective data in a nursing assessment.

Question 2 of 5

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 3 of 5

A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Asking if the patient feels the need to go to the bathroom helps assess urgency. 2. Urinary retention may lead to the inability to sense the urge to void. 3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention. Summary: B: Mobility is not directly related to urinary retention. C: Medication timing is important but not directly related to urinary retention. D: Safety rail inquiry is more related to fall prevention, not urinary retention.

Question 4 of 5

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A because ranking all the patient's nursing diagnoses in order of priority allows the nurse to address the most critical needs first. By prioritizing based on the urgency and potential impact on the patient's health, the nurse can ensure that interventions are carried out effectively. B is incorrect because priorities may need to be adjusted based on the patient's changing condition. C is incorrect as priorities should consider not only physiological but also psychological and sociological factors. D is incorrect because time is an influencing factor, but it should not be the sole consideration when prioritizing interventions.

Question 5 of 5

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.

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