Adult health / medical-surgical nursing · practice question
A 59-year-old client in the intensive care unit is being evaluated for uncontrolled hyperglycemia. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Which documentation should the nurse record to best support safe care and communication?
Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026adult-health-med-surg
Answer and explanation
Correct answer
A. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
Why
Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
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