A nurse is using a flow sheet to document the care of a client who has heart disease and is admitted to a long-term care facility.

Which of the following data should the nurse record on this type of document?

Daily weight, blood pressure, and pulse

Medication administration record.

Nursing diagnosis and care plan.

Discharge planning and referral summary.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is ["A","B","D","E"]

Explanation

The nurse should use the following abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min:.

• O2: This stands for oxygen and indicates the type of gas being delivered to the patient.

• NC: This stands for nasal cannula and indicates the device used to deliver oxygen to the patient.

• SpO2: This stands for peripheral oxygen saturation and indicates the percentage of hemoglobin that is saturated with oxygen in the blood.

It is measured by a pulse oximeter attached to the patient’s finger or earlobe.

• RR: This stands for respiratory rate and indicates the number of breaths per minute that the patient takes.

It is an important vital sign to monitor in patients with respiratory conditions.

Choice C is wrong because LPM is not an accepted abbreviation for oxygen therapy.LPM stands for liters per minute and indicates the flow rate of oxygen being delivered to the patient.However, it should not be abbreviated as LPM, but written out in full or as L/min.This is to avoid confusion with other abbreviations such as lpm (lowercase L) which stands for light per minute, a unit of luminous flux.

Normal ranges for SpO2 and RR vary depending on the age, health status and activity level of the patient, but generally they are:.

• SpO2: 95% to 100% for healthy adults.

Lower values may indicate hypoxemia (low blood oxygen level) or other conditions affecting oxygen delivery or uptake in the body.

• RR: 12 to 20 breaths per minute for healthy adults.

Higher or lower values may indicate respiratory distress, infection, pain, anxiety or other conditions affecting breathing.

A. Redness, swelling, and warmth of the affected area. B. Pain level rated as 8/10 on a numerical scale C. C. Wound culture results pending. D. Risk for infection related to impaired skin integrity. E. Applied moist heat compresses to the wound site.

Correct Answer is ["A","B"]

Explanation

These are the only options that describe thesubjectiveandobjectivedata of the patient, which are part of theSOAPdocumentation method.SOAP stands forSubjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.

ChoiceCis wrong because wound culture results are not part of the assessment entry in SOAP documentation.They are part of the investigation results, which are usually documented in the objective section.

ChoiceDis wrong because risk for infection related to impaired skin integrity is a nursing diagnosis, not an assessment.Nursing diagnoses are usually documented in the plan section of SOAP documentation.

ChoiceEis wrong because applied moist heat compresses to the wound site is an intervention, not an assessment.Interventions are also documented in the plan section of SOAP documentation.

Normal ranges for vital signs are as follows:.

• Blood pressure: 90/60 mmHg to 120/80 mmHg.

• Pulse rate: 60 to 100 beats per minute.

• Respiratory rate: 12 to 20 breaths per minute.

• SpO2: 95% to 100%.

• Temperature: 36.5°C to 37.5°C.

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A nurse is using a flow sheet to document the care of a client who has heart disease and is admitted to a long-term care facility. Which of the following data should the nurse record on this type of document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min. Which of the following abbreviations should the nurse use? (Select all that apply.).

Correct Answer is ["A","B","D","E"]

Explanation

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Correct Answer is ["A","B"]

Explanation

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A nurse is using a flow sheet to document the care of a client who has heart disease and is admitted to a long-term care facility.

Which of the following data should the nurse record on this type of document?