When performing an assessment to determine which medications can be used, which of the following elements is most important?
A. Physical examination
B. Allergies
C. Presence of illness
D. Weight
Correct Answer: B. Allergies
Allergies must be determined so that the nurse does not administer a drug that would be dangerous to the client. The nursing assessment includes gathering information concerning the patient’s individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process.
Option A: Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using age or condition appropriate pain scale. The assessment identifies the current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care.
Option C: Physiological abnormalities manifested by changes in vital signs and level of consciousness often provide early warning signs that patient condition is deteriorating; thus, requiring prompt intervention to forego an adverse outcome, decreasing morbidity and mortality risk. In the fast-paced, resource-challenged healthcare environment today, a thorough assessment can pose a challenge for the healthcare provider but is essential to safe, quality care.
Option D: Initial vital sign measurements include temperature recorded in Celsius in most institutions, respiratory rate, pulse rate, blood pressure with appropriate sized cuff, pulse oximetry reading and note if on room air or oxygen; accurately measured weight in kilograms with the proper scale and height measurement, so body mass index (BMI) is calculable for dosing weights and nutritional guidelines.