Level: Foundational
Difficulty: Easy
Subtopic: Reservoirs and modes of transmission
NCLEX: A 71-year-old client in a long-term care facility is being evaluated for nursing care related to reservoirs and m…
Microbiology Safety and Infection Prevention and Control
Case Study
A 71-year-old client in a long-term care facility is being evaluated for nursing care related to reservoirs and modes of transmission. Assessment data include wound culture grows MRSA with spreading erythema. Which documentation should the nurse record to best support safe care and communication?
Question
A. "Client fine; no changes noted."
B. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
B. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: B. 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.