Level: Foundational
Difficulty: Easy
Subtopic: Respiratory gas exchange
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to respiratory gas ex…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for nursing care related to respiratory gas exchange. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. 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.