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","B"]

Explanation

Kardexes and flow sheets are types of records that are used for documenting concise data about a client and making information quickly accessible to all health professionals.Kardexes are a series of cards kept in a portable index file or on computer generated forms that contain a problem list, stated goals and list of nursing approaches to meet the goals.Flow sheets are forms that allow for recording routine aspects of care such as vital signs, intake and output, medications, etc.

Choice C is wrong because progress notes are not concise, but rather narrative descriptions of the client’s condition, interventions and outcomes.Choice D is wrong because nursing discharge summaries are not used for quick access, but rather for providing information about the client’s hospitalization, treatment and follow-up care.Choice E is wrong because care plan conferences are not records, but meetings where health professionals discuss the client’s needs, goals and progress.

Normal ranges for vital signs 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.

• Respiration: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mmHg.

A. Home health certification and plan of treatment. B. Outcome and assessment information set. C. Home care flow sheet. D. Home care progress note.

Correct Answer is A

Explanation

Home health certification and plan of treatment.This is the record that the nurse uses to certify that the client meets Medicare eligibility criteria and to outline the services to be provided.A home health certification and plan of treatment is a document that contains the physician’s or allowed practitioner’s orders for home health services, the patient’s diagnosis, the patient’s functional limitations, the type and amount of services needed, and the expected duration of care.

Choice B is wrong becauseOutcome and Assessment Information Set (OASIS)is a standardized assessment tool that HHAs use to collect data on adult patients receiving skilled services.

OASIS is not used to certify eligibility or plan treatment.

Choice C is wrong becauseHome care flow sheetis a form that HHAs use to document the daily care provided by nurses and home health aides.

A home care flow sheet does not certify eligibility or plan treatment.

Choice D is wrong becauseHome care progress noteis a form that HHAs use to document the patient’s progress toward the goals of care, any changes in the plan of care, and any communication with other health care providers.

A home care progress note does not certify eligibility or plan treatment.

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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?

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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?