Level: Foundational
Difficulty: Easy
Subtopic: Macronutrients
NCLEX: A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to macronutrients. A…
Nutrition Basic Care and Comfort
Case Study
A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to macronutrients. Assessment data include the client has 6% unintentional weight loss in 1 month and albumin 2.8 g/dL. 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.