Level: Clinical
Difficulty: Medium
Subtopic: Anticoagulants
NCLEX: A 72-year-old client in a long-term care facility is being evaluated for warfarin anticoagulation. Assessment dat…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 72-year-old client in a long-term care facility is being evaluated for warfarin anticoagulation. Assessment data include the client has new facial swelling and difficulty swallowing after the first dose. 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.