Level: Advanced
Difficulty: Hard
Subtopic: Alarm safety
NCLEX: The telehealth nurse during a virtual follow-up visit is being evaluated for technology-supported nursing care an…
Informatics and healthcare technology Management of Care
Case Study
The telehealth nurse during a virtual follow-up visit is being evaluated for technology-supported nursing care and alarm safety. Assessment data include alarm fatigue is reported after repeated nonactionable monitor alarms overnight. 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.