A nurse is preparing to document the admission nursing assessment for a client who has pneumonia.
Which of the following information should the nurse include in this documentation?
The client’s vital signs, oxygen saturation, and respiratory status.
The client’s medical history, allergies, and current medications.
The client’s nursing diagnosis, goals, and expected outcomes.
The client’s family contacts, insurance information, and advance directives.
The Correct Answer is A
The client’s vital signs, oxygen saturation, and respiratory status.
This is because the admission nursing assessment is a comprehensive evaluation of the client’s physical, mental, emotional, and social status, as well as their current health problems and needs.
The admission assessment provides baseline data for comparison and planning of care. The client’s vital signs, oxygen saturation, and respiratory status are essential components of the admission assessment for a client who has pneumonia, as they reflect the severity of the infection and the risk of complications.
Choice B is wrong because the client’s medical history, allergies, and current medications are part of the health history interview, which is a component of the admission assessment but not the entire documentation. Choice C is wrong because the client’s nursing diagnosis, goals, and expected outcomes are part of the planning and implementation phases of the nursing process, which come after the assessment phase. Choice D is wrong because the client’s family contacts, insurance information, and advance directives are part of the administrative data collection, which is not directly related to the client’s health status or nursing care.
Normal ranges for vital signs vary depending on age, gender, and health conditions, but generally they are as follows:.
• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: less than 120/80 mm Hg.
• Oxygen saturation: 95% to 100%.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
It allows access to client information from multiple locations.
This is an advantage of using a computerized system for documentation and reporting because it enables health care providers to access relevant and updated information about their clients from different locations, such as hospitals, clinics, or home care settings.This can improve the quality and continuity of care, as well as facilitate communication and collaboration among different members of the health care team.
Choice A is wrong because it is not true that a computerized system eliminates errors and inaccuracies in documentation.While a computerized system can reduce some types of errors, such as illegible handwriting or misplaced files, it can also introduce new types of errors, such as data entry mistakes, software glitches, or system failures.
Choice C is wrong because it is not true that a computerized system reduces the need for verbal or written communication among health care providers.On the contrary, a computerized system can enhance communication by allowing health care providers to share information more easily and quickly, but it does not replace the need for verbal or written communication to clarify, confirm, or discuss the information.
Choice D is wrong because it is not true that a computerized system protects client information from unauthorized disclosure or alteration.
While a computerized system can provide some security features, such as passwords, encryption, or audit trails, it can also pose some risks, such as hacking, phishing, or malware attacks.Therefore, health care providers need to follow ethical and legal guidelines to ensure the confidentiality and integrity of client information in a computerized system.
Correct Answer is D
Explanation
“I read back the order for a chest x-ray for Mr. Jones in room 20.”.
This is the best way to verify a telephone order from a radiologist, as it ensures that the nurse has accurately transcribed the order and that the radiologist has confirmed it.
Reading back the order also allows the nurse to clarify any doubts or questions about the order, such as the urgency, the reason, or the patient’s condition.
Choice A is wrong because it does not verify the order, but simply repeats it.
The nurse should not assume that the order is correct without confirmation from the radiologist.
Choice B is wrong because it asks the radiologist to repeat the order, which is inefficient and may cause confusion or errors.
The nurse should repeat the order to the radiologist, not the other way around.
Choice C is wrong because it uses a closed-ended question that can be answered with a yes or no, which may not reflect the radiologist’s true intention or understanding of the order.
The nurse should use an open-ended statement that requires the radiologist to acknowledge or correct the order.
According to federal regulations and accreditation standards, verbal and telephone orders should be authenticated by the prescriber within a specified time frame, usually 24 hours.Some states may have different or more stringent requirements, so nurses should be familiar with their state laws and regulations.Verbal and telephone orders should also be documented and signed by two nurses or one nurse and one enrolled endorsed nurse for verification and administration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.