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Zorluk: OrtaData Collection Techniques

A practical nurse (PN) is gathering focused physical data on an older adult client who was just admitted to the medical-surgical unit with a suspected respiratory infection. Which of the following actions by the PN are appropriate? Select all that apply.

  1. Auscultating the anterior, posterior, and lateral lung fields systematicallyCevap
  2. B
    Documenting a new onset of disorientation to place and time as expected age-related changes
  3. Inspecting the client's oral mucous membranes, nail beds, and skin color for cyanosisCevap
  4. D
    Formulating a comprehensive independent nursing diagnosis for impaired gas exchange based on the breath sounds
  5. Verifying the client's apical pulse for one full minute using a stethoscopeCevap
  6. F
    Charting a resting heart rate of 112 beats/min and blood pressure of 88/56 mm Hg as stable without immediately reporting them

Cevap

The correct actions include auscultating the lung fields systematically, inspecting for cyanosis, and verifying the apical pulse for one full minute.
The appropriate data collection actions within the PN scope of practice include systematically auscultating all lung fields to detect abnormal breath sounds, inspecting mucous membranes and skin for cyanosis (which indicates hypoxia), and obtaining an accurate apical pulse for one full minute to assess cardiovascular function. These focused data collection techniques provide vital baseline information to share with the supervising RN or healthcare provider.

Adım Adım Çözüm

1
Identify the role and scope of the practical nurse (PN) in data collection.
The PN performs focused physical observations and gathers objective baseline data to report to the RN or provider.
The PN contributes to the assessment process but does not independently diagnose or formulate the initial comprehensive plan of care.
2
Evaluate each action for clinical appropriateness in the context of an older adult with a respiratory infection.
Auscultating lung fields, inspecting for cyanosis, and taking a full-minute apical pulse are all appropriate, within-scope data collection techniques.
These techniques yield objective data essential for monitoring the client's respiratory and cardiovascular status.
3
Identify actions that represent clinical errors or out-of-scope practices.
Assuming new confusion is normal aging, making independent nursing diagnoses, and failing to report borderline vital signs are incorrect.
Acute confusion is a sign of delirium or hypoxia, diagnosis is an RN responsibility, and abnormal vitals require immediate escalation.

Anahtar Kavram

Data Collection Techniques within PN Scope of Practice
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Data Collection Techniques

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