A nurse is documenting the findings of a head-to-toe assessment on a newly admitted client.
Which of the following information should the nurse include in the documentation?
The client's vital signs are within normal limits.
The client's skin is warm, dry, and intact.
The client's bowel sounds are present in all four quadrants.
All of the above.
The Correct Answer is D
Rationale: The nurse should document all relevant and objective data obtained from the assessment, including vital signs, skin condition, bowel sounds, and any other findings that reflect the client's health status.
Incorrect options:
A) The client's vital signs are within normal limits. - This is a correct statement, but it is not the only information that should be documented.
B) The client's skin is warm, dry, and intact. - This is a correct statement, but it is not the only information that should be documented.
C) The client's bowel sounds are present in all four quadrants. - This is a correct statement, but it is not the only information that should be documented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client's chest x-ray shows clear lung fields.
Rationale: A chest x-ray is a diagnostic test that can confirm the presence or absence of pneumonia by showing areas of consolidation or infiltration in the lung tissue. A clear chest x-ray indicates resolution of pneumonia and effectiveness of treatment.
Incorrect options:
A) The client's temperature is 37.2°C (99°F). - This is a normal finding, but it does not rule out pneumonia as some clients may have low-grade fever or no fever at all with pneumonia.
B) The client's white blood cell count is 12.5 x 10^9/L. - This is an elevated finding, as the normal range for white blood cell count is 4.5 to 11 x 10^9/L. An elevated white blood cell count indicates inflammation or infection and does not reflect the effectiveness of treatment.
C) The client's oxygen saturation is 95% on room air. - This is a normal finding, as the normal range for oxygen saturation is 95% to 100%. However, it does not indicate the severity or resolution of pneumonia, as some clients may have normal oxygen saturation despite having pneumonia.
Correct Answer is D
Explanation
Rationale: The nurse should document all relevant and objective data obtained from the assessment, including vital signs, skin condition, bowel sounds, and any other findings that reflect the client's health status.
Incorrect options:
A) The client's vital signs are within normal limits. - This is a correct statement, but it is not the only information that should be documented.
B) The client's skin is warm, dry, and intact. - This is a correct statement, but it is not the only information that should be documented.
C) The client's bowel sounds are present in all four quadrants. - This is a correct statement, but it is not the only information that should be documented.
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