Level: Foundational
Difficulty: Easy
Subtopic: Immunizations
NCLEX: A 6-month-old infant in the pediatric clinic is being evaluated for routine childhood immunizations. Assessment d…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 6-month-old infant in the pediatric clinic is being evaluated for routine childhood immunizations. Assessment data include nasal flaring, grunting, retractions, and SpO2 89%. 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.