Nursing fundamentals · practice question

A 76-year-old client in a long-term care facility is being evaluated for nursing care related to documentation fundamentals. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Which documentation should the nurse record to best support safe care and communication?

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

Answer and explanation

Correct answer

C. 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 76-year-old client in a long-term care facility is being evaluated for nursing care related to documentation fundamentals. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Which documentation should the nurse record to best support safe care and communication?

Correct answer

Why

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