Level: Clinical
Difficulty: Medium
Subtopic: Clinical practice guidelines
NCLEX: The RN evaluating a clinical practice guideline is being evaluated for evidence-based practice and clinical pract…
Statistics or evidence-based practice Management of Care
Case Study
The RN evaluating a clinical practice guideline is being evaluated for evidence-based practice and clinical practice guidelines. Assessment data include fall rates increased from 2.1 to 4.8 per 1,000 patient days after a process change. 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. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
D. Subjective opinions only without measurable findings.
B. Copied yesterday's note without updating current assessment data.
C. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: C. 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.