Ethics, legal nursing, delegation, prioritization · practice question

A 58-year-old client on a telemetry unit is being evaluated for nursing care related to scope of practice. Assessment data include provider order for a medication the client is allergic to on the chart. 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."Client fine; no changes noted."Copied yesterday's note without updating current assessment data.Subjective opinions only without measurable findings.

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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A 58-year-old client on a telemetry unit is being evaluated for nursing care related to scope of practice. Assessment data include provider order for a medication the client is allergic to on the chart. Which documentation should the nurse record to best support safe care and communication?

Correct answer

Why

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