A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

Chart a summary of the data at the change of the shift.

Note whether the client has a living will.

Document the client's vital signs obtained by assistive personnel.

Begin charting with an evaluation of the data.

Answer and Explanation

The Correct Answer is D

A. Chart a summary of the data at the change of the shift - Documenting a summary of data at the change of shift is appropriate for communication among healthcare providers but should not be the first action. It's important to document all relevant admission data promptly and accurately.
B. Note whether the client has a living will - While documenting the client's living will status is important for their care, it's not the first action to take during admission documentation. Immediate assessment and documentation of essential data related to the client's condition and history take priority.
C. Document the client's vital signs obtained by assistive personnel - Documenting vital signs obtained by assistive personnel is appropriate, but it should not be the first action. The nurse should first conduct a comprehensive assessment and document all relevant admission data.
D. Begin charting with an evaluation of the data - This is the most appropriate action. The nurse should start by evaluating and documenting the admission data systematically and comprehensively. This includes the client's chief complaint, medical history, allergies, current medications, vital signs, physical assessment findings, and any other pertinent information. Starting with an evaluation ensures that all relevant data are captured and documented accurately.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. A client who has a right peripherally inserted central catheter (PICC):
When a client has a right-sided PICC, it's essential to measure blood pressure in the left arm. This is because the PICC line can interfere with accurate blood pressure readings on the right side due to the placement of the cuff and potential obstruction of blood flow. Measuring blood pressure in the left arm provides a more accurate assessment of systemic blood pressure.

B. A client who had a right hemisphere stroke:
While clients with a right hemisphere stroke may have various neurological deficits, there is no specific indication to measure blood pressure in the left arm based solely on this condition.

C. A client who had blood drawn from the right antecubital area 1 hr ago:
Blood drawn from the antecubital area typically does not affect blood pressure measurements in the same arm. Therefore, there is no need to measure blood pressure in the opposite arm in this situation.

D. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm:
While clients with arteriovenous shunts may have altered blood flow dynamics, the use of a shunt in the left lower forearm does not necessarily require blood pressure measurements to be taken in the opposite arm. Blood pressure measurement should be performed on the side without the shunt unless contraindicated for other reasons.

A. Activate the fire alarm system. B. Evacuate clients from the area. C. Obtain and use a fire extinguisher. D. Close the doors and windows on the unit.

Correct Answer is B

Explanation

Answer: B

Rationale:

A) Activate the fire alarm system:

While activating the fire alarm system is essential in alerting everyone to the fire, the immediate safety of the clients must be prioritized first. Ensuring clients are safe from potential harm should precede alerting others.

B) Evacuate clients from the area:

Evacuating clients from the area is the first priority as it directly ensures their safety. In the event of a fire, removing individuals from the source of danger is crucial to prevent injury or harm.

C) Obtain and use a fire extinguisher:

Using a fire extinguisher to put out the fire is important, but it should not be the first action. Ensuring clients are evacuated to safety must take precedence before attempting to control the fire.

D) Close the doors and windows on the unit:

Closing doors and windows can help contain the fire and smoke, but this should follow the evacuation of clients. The primary concern is to get clients to a safe area first before taking measures to contain the fire.

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A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

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