Fundamentals of Nursing Q 257
Which of the following is an example of data that should be validated?
A. The urinalysis report indicates there are white blood cells in the urine.
B. The client states she feels feverish; you measure the oral temperature at 98°F.
C. The client has clear breath sounds; you count a respiratory rate of 18.
D. The chest x-ray report indicates the client has pneumonia in the right lower lobe.
Correct Answer: B. The client states she feels feverish; you measure the oral temperature at 98°F.
Validation should be done when subjective and objective data do not make sense. For instance, it is inconsistent data when the patient feels feverish and you obtain a normal temperature. The other distractors do not offer conflicting data. Validation is not usually necessary for laboratory test results.
Option A: When this test is positive and/or the WBC count in urine is high, it may indicate that there is inflammation in the urinary tract or kidneys. The most common cause for WBCs in urine (leukocyturia) is a bacterial urinary tract infection (UTI), such as a bladder or kidney infection.
Option C: Breath sounds are the noises produced by the structures of the lungs during breathing. Normal lung sounds occur in all parts of the chest area, including above the collarbones and at the bottom of the rib cage. Using a stethoscope, the doctor may hear normal breathing sounds, decreased or absent breath sounds, and abnormal breath sounds. Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.
Option D: The most common organisms which cause lobar pneumonia are Streptococcus pneumoniae, also called pneumococcus, Haemophilus influenza, and Moraxella catarrhalis. Mycobacterium tuberculosis, the tubercle bacillus, may also cause lobar pneumonia if pulmonary tuberculosis is not treated promptly.