CHAPTER 1 Foundations for Clinical Proficiency
MULTIPLE CHOICE
1. After completing an initial assessment of a patient, the nurse has charted that his
... [Show More] respirations
are eupneic and his pulse is 58 beats per minute. These types of data would be:
a
.
Objective.
b
.
Reflective.
c
.
Subjective.
d
.
Introspective.
ANS: A
Objective data are what the health professional observes by inspecting, percussing, palpating,
and auscultating during the physical examination. Subjective data is what the person says about
him or herself during history taking. The terms reflective and introspective are not used to
describe data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of
data would be:
a
.
Objective.
b
.
Reflective.
c
.
Subjective.
d
.
Introspective.
ANS: C
Subjective data are what the person says about him or herself during history taking. Objective
data are what the health professional observes by inspecting, percussing, palpating, and
auscultating during the physical examination. The terms reflective and introspective are not used
to describe data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The patients record, laboratory studies, objective data, and subjective data combine to form
the:
a
.
Data base.
b
.
Admitting data.
c
.
Financial statement.
d
.
Discharge summary.
ANS: A
Together with the patients record and laboratory studies, the objective and subjective data form
the data base. The other items are not part of the patients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
nurses next action should be to:
a
.
Immediately notify the patients physician.
b
.
Document the sound exactly as it was heard.
c
.
Validate the data by asking a coworker to listen to the breath sounds.
d
.
Assess again in 20 minutes to note whether the sound is still present.
ANS: C
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the
data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert
to listen.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care [Show Less]