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Difficulty: EasyData Collection Techniques

A practical nurse (PN) is collecting admission data for a young adult client who is scheduled for an elective surgical procedure. Which of the following actions by the PN demonstrate appropriate data collection techniques? (Select all that apply.)

  1. Documenting the client's chief complaint using their exact words enclosed in quotation marks.Answer
  2. B
    Delaying the measurement of respiratory rate and oxygen saturation because the client is reporting severe localized pain.
  3. C
    Asking the client, "Why did you wait so long to seek medical treatment?" to establish the timeline of the illness.
  4. Applying the blood pressure cuff directly to the client's bare arm rather than measuring over their clothing.Answer
  5. E
    Completing the initial, comprehensive admission assessment independently to establish the client's nursing care plan.
  6. Verifying the client's identity by asking them to state their full name and date of birth while checking the identification band.Answer

Answer

The correct actions include documenting the chief complaint using exact quotes, applying the blood pressure cuff to a bare arm, and asking the client to state their name and date of birth.
The correct actions demonstrate fundamental data collection techniques within the practical nurse's scope of practice. Documenting exact quotes provides accurate subjective data without interpretation. Measuring blood pressure on a bare arm ensures an accurate reading, as clothing can alter the result. Having the client actively state their name and date of birth is the standard technique for ensuring correct patient identification before proceeding with any data collection or care.

Step-by-Step Solution

1
Review the clinical scenario and the specific task requested.
The scenario requires identifying proper data collection techniques for a PN admitting a young adult client.
Understanding the role and clinical context is essential to safely applying data collection guidelines.
2
Evaluate each option based on standard physical assessment techniques and therapeutic communication.
Documenting exact quotes, measuring blood pressure on bare skin, and using two active identifiers are all correct, foundational data collection techniques.
These actions follow evidence-based guidelines for accurate data gathering and patient safety.
3
Identify the incorrect actions based on clinical safety priorities and the PN scope of practice.
Delaying respiratory assessments for pain, using "why" questions, and performing the comprehensive initial assessment are incorrect.
These actions violate ABC prioritization, utilize non-therapeutic communication, and exceed the legal scope of practice for a practical nurse.

Key Concept

Foundational Data Collection Techniques and Scope of Practice
Estimated Time:1m 0s
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Data Collection Techniques

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