After completing an initial assessment of a patient, the nurse has charted that his respirationsare eupneic and his
pulse is 58 beats per minute. What
... [Show More] type of assessment data is this?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: A
Objective data is 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 usedto describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. A patient tells the nurse that he is very nervous, nauseous, and “feels hot.” What type ofassessment data is
this?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: C
Subjective data is what the person says about him or herself during history taking. Objectivedata is 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)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. What do the patient’s record, laboratory studies, objective data, and subjective data combineto form?
a. Database
b. Admitting data
c. Financial statement
d. Discharge summary
ANS: A
Together with the patient’s record and laboratory studies, the objective and subjective data form the database. The
other items are not part of the patient’s record, laboratory studies, ordata.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4
4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard.Which action should
the nurse take
next?
a. Notify the patient’s physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking another nurse 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 patient’s breath sounds, the nurse validates the data to ensure
accuracy by either repeating the assessment themselves or asking another nurse to assess the breath sounds. If the
nurse has less experience analyzing breath sounds, then he or she should ask an expert to listen. When unsure of a
sound heard while listening toa patient’s breath sounds, the nurse should validate the data before documenting to
ensure accuracy and before notifying the patient’s physician. To validate that data, the nurse either repeats the
assessment himself or herself or asks another nurse to assess the breath sounds.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. The nurse is conducting a class for new graduate nurses. While teaching the class, what should the nurse keep in
mind regarding what novice nurses, without a background of skills and experience from which to draw upon, are
more likely to base their decisions on?
a. Intuition
b. A set of rules
c. Articles in journals
d. Advice from supervisors
ANS: B
Novice nurses operate from a set of defined, structured rules to make decisions. It takes time,perhaps a few years, in
similar clinical situations to achieve competency and it is functioning at the level of an expert practitioner when
intuition is included in making clinical decisions. Intuition is included in decision making when functioning at the level of
an expert practitioner. While information in journal articles and advice from supervisors may assist in making
decisions, novice nurses do not typically base their decisions on them. It would also be important that if information
from journal articles and advice from supervisors were used,that they were evidence based. [Show Less]