Level: Clinical
Difficulty: Medium
Subtopic: Endocrine disorders
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for uncontrolled hyperglycemia. Assessment dat…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for uncontrolled hyperglycemia. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Which documentation should the nurse record to best support safe care and communication?
Question
A. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
B. "Client fine; no changes noted."
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
B. "Client fine; no changes noted."
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: A. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.