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.

Answer and Explanation

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%.

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Correct Answer is A

Explanation

Daily weight, blood pressure, and pulse.

A flow sheet is a type of document that records specific information in a structured and concise way, such as vital signs, fluid intake and output, pain level, etc.A flow sheet is useful for clinical communication and tracking the patient’s condition over time.A medication administration record (MAR) is a separate document that records the medications given to the patient, the dosage, the route, and the time.A nursing diagnosis and care plan is a document that identifies the patient’s problems and goals, and the interventions to achieve them.A discharge planning and referral summary is a document that outlines the patient’s needs and resources after leaving the facility, such as follow-up appointments, home care services, etc.

These documents are not part of a flow sheet.

Choice B is wrong because a MAR is not a flow sheet.

Choice C is wrong because a nursing diagnosis and care plan is not a flow sheet.

Choice D is wrong because a discharge planning and referral summary is not a flow sheet.

Normal ranges for daily weight vary depending on the patient’s age, height, gender, and medical condition.However, a general guideline is that a weight gain or loss of more than 2 kg (4.4 lbs) in a week or 0.9 kg (2 lbs) in a day may indicate fluid retention or dehydration.Normal ranges for blood pressure are less than 120/80 mmHg for adults, and less than 95/65 mmHg for children.Normal ranges for pulse are 60 to 100 beats per minute for adults, and 70 to 120 beats per minute for children.

A. Data. B. Problem. C. Focus. D. Assessment.

Correct Answer is C

Explanation

Focus.

Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions.The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.

The focus charting method uses three columns: date and hour, focus, and progress notes.The progress notes are organized into data, action, and response, referred to as DAR.

Choice A is wrong because data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus.Choice B is wrong because problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care.Choice D is wrong because assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.

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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?