Level: Foundational
Difficulty: Easy
Subtopic: Delegation to assistive personnel
NCLEX: The charge nurse on a medical-surgical unit is being evaluated for nursing care related to delegation to assistiv…
Leadership and management Management of Care
Case Study
The charge nurse on a medical-surgical unit is being evaluated for nursing care related to delegation to assistive personnel. Assessment data include new chest pain rated 8/10 with diaphoresis. 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.