Question

A patient complains of not feeling well and is coughing frequently with copious phlegm. Coughing is worse at night. During the initial assessment, the nurse finds that the patient coughs violently for 40 to 45 seconds with thick, yellow phlegm. The blood pressure is 150/90 mm Hg, pulse rate is 92 beats/minute, and respiratory rate is 22 breaths/minute. Wheezing and rhonchi are present in both lung bases. The patient expresses having chest pain when coughing and the pain radiates to the arm. Which data should the nurse document as objective data? Select all that apply.

1. Chest pain
2. Blood pressure
3. Thick, yellow phlegm
4. Pain radiating to the arm
5. Presence of wheezes and rhonchi

Answer 1

Objective data for documentation includes coughing frequency and characteristics, vital signs, and the presence of wheezes and rhonchi during auscultation.

Step-by-step explanation:

The nurse should document the following as objective data in a patient's health record: the coughing frequency and duration, the characteristics of the phlegm (thick, yellow), the vital signs including blood pressure (150/90 mm Hg), pulse rate (92 beats/minute), and respiratory rate (22 breaths/minute). In addition, the presence of wheezing and rhonchi that were observed in both lung bases during auscultation should be documented as objective findings. These data points are directly observed or measured by the healthcare provider during the exam.