NCLEX-PN

Category - Coordinated Care

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In documenting the care given, which statement shows good documentation?

Documenting the client’s response to the intervention
Documenting the assumptions of the nurse
Giving facts and opinions regarding the client’s behavior
Omitting data pertaining to medications that are not given

Explanation

Answer: A - Documentation is the process of putting down in writing all nursing care activities given to the client. Documentation should be factual, accurate, and precise. The nurse should refrain from giving assumptions and opinions regarding the client and the care given. The nurse should document the medications that were given and were ordered but not given.

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