Client Assessment and Planning Flashcards

An RPN is completing an admission assessment on a new client. Which of the following is the best example of objective data?

Answer: The client's respiratory rate is 24 breaths per minute and slightly labored.

Objective data consists of observable and measurable information gathered by the healthcare professional. A respiratory rate of 24 is a measurable vital sign, and the observation of labored breathing is a direct clinical sign. The other options are examples of subjective data, which are reported by the client or their family.

When an RPN collaborates with a client to establish goals for their plan of care, which principle is essential for creating an effective goal statement?

Answer: The goal must be measurable and include a specific timeframe for achievement.

Effective goals in a nursing care plan should follow the SMART criteria: Specific, Measurable, Achievable, Relevant, and Time-bound. A measurable goal with a timeframe, such as "The client will walk 20 meters with a walker by the end of the week," allows the healthcare team to accurately evaluate the client's progress.

A client is admitted to the hospital with an acute exacerbation of heart failure. They are experiencing shortness of breath, bilateral crackles on auscultation, and 2+ pitting edema in their lower extremities. What is the RPN's priority assessment?

Answer: Respiratory status.

Using the ABCs (Airway, Breathing, Circulation) prioritization framework, the client's respiratory status is the most immediate concern. Shortness of breath and crackles indicate impaired gas exchange and fluid in the lungs, which is a life-threatening condition that requires priority assessment and intervention.

An RPN is caring for a post-operative client who has a new order to ambulate. Before developing a plan to get the client out of bed for the first time, what is the most important initial assessment the RPN should perform?

Answer: The client's vital signs and level of pain.

Assessing the client's physiological stability through vital signs and determining their level of pain is the priority before any new physical activity. This initial data helps the nurse determine if the client is stable enough to tolerate ambulation and if pain management is needed to facilitate the activity safely.

Which of the following represents a correctly formulated nursing diagnosis?

Answer: Risk for Infection related to surgical incision.

A 'Risk For' nursing diagnosis includes the diagnostic label and the related risk factors. 'Risk for Infection related to surgical incision' correctly identifies a potential problem and its cause. 'Pneumonia' is a medical diagnosis. The other options are incomplete nursing diagnoses as they lack either the related factors or the defining characteristics/evidence.

An RPN is conducting a health history with an older adult client who has recently lost weight. To gather comprehensive data during the assessment phase, which action is most appropriate?

Answer: Use a combination of open-ended and focused questions about their diet and health.

The assessment phase of the nursing process involves gathering comprehensive subjective and objective data. Using open-ended questions encourages the client to share their story, while focused questions help clarify specific details. This combination ensures the nurse gathers thorough and relevant information about the client's weight loss and overall health status.