Level: Foundational
Difficulty: Easy
Subtopic: Autonomy and informed consent
NCLEX: A 58-year-old client on a telemetry unit is being evaluated for nursing care related to autonomy and informed con…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 58-year-old client on a telemetry unit is being evaluated for nursing care related to autonomy and informed consent. Assessment data include telephone order received for a high-risk IV medication. Which documentation should the nurse record to best support safe care and communication?
Question
A. "Client fine; no changes noted."
B. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
B. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: B. 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.