A nurse is documenting admission data for a client on an acute care facility.
Which of the following actions should the nurse take?

Document the client's vital signs obtained by an assistive personnel.

Chart a summary of the data at the change of the shift.

Note whether the client has a living will.

Begin charting with an evaluation of the data.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Documenting the client's vital signs obtained by an assistive personnel is correct. Documenting vital signs is fundamental and immediate requirement when admitting a client to ensure their current health status is accurately captured and can be monitored effectively.

Choice B rationale:

Charting a summary of the data at the change of the shift is incorrect. While it's essential to provide an update at shift change, this option suggests summarizing the data, which might not include all necessary details. Comprehensive documentation is crucial for continuity of care and accurate communication among healthcare providers. Documenting specific vital signs, assessments, interventions, and the client's response to those interventions is necessary for effective patient care.

Choice C rationale:

Noting whether the client has a living will is incorrect. While it's essential to be aware of a client's advanced directives, this information is typically gathered during the admission process or during routine assessments. It is not the immediate action to be taken upon admission. Vital signs and other immediate clinical data take precedence during the initial documentation process.

Choice D rationale:

Beginning charting with an evaluation of the data is incorrect. It is important to document objective data, such as vital signs, observations, and assessments, before making any evaluations or interpretations. Objective data provide the basis for clinical decisions and interventions. Starting with evaluations might lead to biased documentation, potentially overlooking important clinical findings.

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Correct Answer is B

Explanation

"Have you had any stomach pain or bloody stools?"

Rationale:

A. Muscle stiffness is not a common or serious adverse effect of ibuprofen. Ibuprofen is an antiinflammatory drug that can reduce pain and stiffness caused by arthritis.
B. Stomach pain or bloody stools are signs of gastrointestinal bleeding, which is a serious and potentially fatal adverse effect of ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause ulceration, perforation, and hemorrhage of the stomach or intestines . The nurse should ask the client about any gastrointestinal symptoms and advise them to avoid alcohol, smoking, and other NSAIDs while taking ibuprofen.
C. Dry cough is not a common or serious adverse effect of ibuprofen. Dry cough is more likely to be caused by angiotensin-converting enzyme (ACE) inhibitors, which are used to treat hypertension and heart failure.
D. Increase in urine output is not a common or serious adverse effect of ibuprofen. Ibuprofen can cause renal impairment, which can lead to decreased urine output, not increased urine output. The nurse should monitor the client's renal function tests and fluid balance while taking ibuprofen.

A. Obesity B. Acromegaly C. Estrogen replacement therapy D. Sedentary lifestyle

Correct Answer is D

Explanation

- A. Obesity is not a risk factor for osteoporosis. In fact, obesity may have a protective effect on bone density due to increased mechanical loading and higher levels of estrogen in adipose tissue.

- B. Acromegaly is not a risk factor for osteoporosis. Acromegaly is a condition caused by excess growth hormone, which leads to increased bone formation and remodeling.

- C. Estrogen replacement therapy is not a risk factor for osteoporosis. Estrogen replacement therapy can help prevent bone loss and reduce the risk of fractures in postmenopausal women with low estrogen levels.

- D. Sedentary lifestyle is a risk factor for osteoporosis. Sedentary lifestyle reduces physical activity and muscle strength, which decreases bone stimulation and increases bone resorption.

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A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

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A nurse is documenting admission data for a client on an acute care facility.
Which of the following actions should the nurse take?