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.
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
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%.
Correct Answer is D
Explanation
To provide continuity of care.
A care plan conference is a meeting between the nursing home staff, the resident, and the resident’s family to set measurable, specific goals for the resident to meet during their stay, decide what needs to be done to meet those goals, and decide who in the nursing home is responsible for performing each job necessary to help the resident.The main purpose of this meeting is to provide continuity of care, which means ensuring that the resident receives consistent and coordinated care across different settings and providers.
Choice A is wrong becauseto discuss possible solutions to certain client problemsis not the main purpose of a care plan conference, although it may be one of the topics discussed.
A care plan conference is not meant to address only specific problems, but rather the overall plan of care for the resident.
Choice B is wrong becauseto evaluate the effectiveness of the care givenis not the main purpose of a care plan conference, although it may be one of the outcomes of the meeting.
A care plan conference is not meant to assess only the performance of the staff, but rather the progress of the resident.
Choice C is wrong becauseto gather information for the plan of careis not the main purpose of a care plan conference, although it may be one of the steps involved.
A care plan conference is not meant to collect only information, but rather to use it to develop and update the plan of care.
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