Health assessment · practice question

A 74-year-old client on a medical-surgical unit is being evaluated for skin and wound assessment during hospitalization. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. Which documentation should the nurse record to best support safe care and communication?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026health-assessment

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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