Level: Foundational
Difficulty: Easy
Subtopic: Normal flora and opportunistic infection
NCLEX: A 52-year-old client on a medical-surgical unit is being evaluated for nursing care related to normal flora and o…
Microbiology Safety and Infection Prevention and Control
Case Study
A 52-year-old client on a medical-surgical unit is being evaluated for nursing care related to normal flora and opportunistic infection. Assessment data include isolation precautions ordered for confirmed pulmonary tuberculosis. 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.