Level: Clinical
Difficulty: Medium
Subtopic: Dehydration
NCLEX: A 6-month-old infant in the pediatric clinic is being evaluated for dehydration from vomiting and diarrhea. Asses…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 6-month-old infant in the pediatric clinic is being evaluated for dehydration from vomiting and diarrhea. Assessment data include temperature 103.1°F (39.5°C) with a new petechial rash. 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. Subjective opinions only without measurable findings.
D. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
B. Copied yesterday's note without updating current assessment data.
C. Subjective opinions only without measurable findings.
D. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
Rationale
Correct answer: D. 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.