Clinical judgment / Next Gen NCLEX case studies · practice question

An RN prioritizing care after a change in status is being evaluated for nursing care related to evaluate outcomes. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Which documentation should the nurse record to best support safe care and communication?

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Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.Subjective opinions only without measurable findings.Copied yesterday's note without updating current assessment data."Client fine; no changes noted."

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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