Documentation and Hand-Off Communication · NCLEX Exam

What is an essential element of documentation related to nursing interventions?

  1. Omitting reassessment if the patient appears stable
  2. Documenting interventions only once per shift
  3. Linking nursing action with patient response and outcome
  4. Recording only subjective reports
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Correct answer: Linking nursing action with patient response and outcome

Documentation must reflect the intervention, patient response, and outcome to capture the full nursing process.

Difficulty: Easy Question 6 of 20

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