Level: Foundational
Difficulty: Easy
Subtopic: Hygiene and comfort
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for nursing care related to hygiene and comf…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 76-year-old client in a long-term care facility is being evaluated for nursing care related to hygiene and comfort. Assessment data include pain 9/10 and guards the abdomen after surgery. Which documentation should the nurse record to best support safe care and communication?
Question
A. "Client fine; no changes noted."
B. Copied yesterday's note without updating current assessment data.
C. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
D. Subjective opinions only without measurable findings.
B. Copied yesterday's note without updating current assessment data.
C. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: C. 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.