A nurse is preparing a report for a client who is being transferred to another unit.
Which of the following statements should the nurse include in the report?
“The client is alert and oriented to person, place, and time.”.
“The client has a history of hypertension and diabetes.”.
“The client’s vital signs are stable and within normal limits.”.
“The client needs assistance with bathing and dressing.”.
The Correct Answer is A
“The client is alert and oriented to person, place, and time.”
This statement provides the most relevant and current information about the client’s mental status and level of consciousness, which are important for the receiving nurse to know.
The other statements are either too vague (C), too general (B), or not a priority (D) for a transfer report.
Choice B is wrong because it does not specify the current status of the client’s hypertension and diabetes, such as blood pressure, blood glucose, medications, or complications.
This information is more appropriate for a written summary or a discharge report.
Choice C is wrong because it does not provide the actual values of the client’s vital signs, which can vary depending on the client’s condition and baseline.
The receiving nurse should know the exact numbers to monitor for any changes or abnormalities.
Choice D is wrong because it does not indicate the reason why the client needs assistance with bathing and dressing, such as mobility issues, pain, or weakness.
This information is also less urgent than the client’s mental status and vital signs.
Normal ranges for vital signs are:.
• Temperature: 36.5°C to 37.2°C (97.7°F to 99°F).
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: less than 120/80 mm Hg.
Sources:.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“The client is alert and oriented to person, place, and time.”
This statement provides the most relevant and current information about the client’s mental status and level of consciousness, which are important for the receiving nurse to know.
The other statements are either too vague (C), too general (B), or not a priority (D) for a transfer report.
Choice B is wrong because it does not specify the current status of the client’s hypertension and diabetes, such as blood pressure, blood glucose, medications, or complications.
This information is more appropriate for a written summary or a discharge report.
Choice C is wrong because it does not provide the actual values of the client’s vital signs, which can vary depending on the client’s condition and baseline.
The receiving nurse should know the exact numbers to monitor for any changes or abnormalities.
Choice D is wrong because it does not indicate the reason why the client needs assistance with bathing and dressing, such as mobility issues, pain, or weakness.
This information is also less urgent than the client’s mental status and vital signs.
Normal ranges for vital signs are:.
• Temperature: 36.5°C to 37.2°C (97.7°F to 99°F).
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: less than 120/80 mm Hg.
Sources:.
Correct Answer is A
Explanation
“It helps us to communicate with other members of the health care team.”.
Nursing documentation is essential for clinical communication.Documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver individualised care.
Choice B is wrong because reimbursement is not the primary purpose of nursing documentation, although it may be a secondary benefit.
Choice C is wrong because legal liability is not the main reason for documenting care, although it may provide evidence in case of litigation.
Choice D is wrong because quality improvement is not the direct result of nursing documentation, although it may be facilitated by it.
Nursing documentation should follow six essential principles: documentation characteristics, education and training, policies and procedures, protection systems, documentation entries and standardized terminologies.
These principles help nurses to create clear, accurate and accessible records that can improve patient outcomes and safety.
: ANA’s Principles for Nursing Documentation - ANA Enterprise: Clinical Guidelines (Nursing) : Nursing Documentation Principles.
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