Detailed Answer Key Final Health Assessment - Final Study Guide Key

Detailed Answer Key Final Health Assessment - Final Study Guide Key 1. An assistive personnel (AP) reports a client’s vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure? A. BP Rationale: A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions. B. Respiratory rate Rationale: This respiratory rate is within the expected reference range. Unless it deviates markedly from the client’s usual readings, the nurse need not take any action at this time. C. Pulse rate Rationale: This pulse rate is within the expected reference range. Unless it deviates markedly from the client’s usual readings, the nurse need not take any action at this time. D. Temperature Rationale: This temperature reading is within the expected reference range. Unless it deviates markedly from the client’s usual readings, the nurse need not take any action at this time. 2. A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client’s medical record? A. "There were no injuries sustained." Rationale: The nurse should document the facts, which includes objective and subjective data and not make suppositions about whether injuries were sustained. B. "An incident report was completed." Rationale: Documenting that an incident report was completed is not appropriate for the nurse to include in the chart. C. "An incident report was forwarded to risk management." Rationale: Documenting that an incident report was forwarded to risk management is not appropriate for the nurse to include in the chart. D. "The provider was notified." Rationale: Nursing interventions that support factual information should be documented in the health