Level: Foundational
Difficulty: Easy
Subtopic: Prioritize hypotheses
NCLEX: An RN prioritizing care after a change in status is being evaluated for nursing care related to prioritize hypoth…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
An RN prioritizing care after a change in status is being evaluated for nursing care related to prioritize hypotheses. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. 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.