# Situation: A 34-year-old man with a closed fracture of the left femur is in skeletal traction on the orthopedic ward, 1 day after admission. The ward keeps a Kardex for each client and writes its nursing notes on paper. The resident examines him at 03:15 and orders a different analgesic. Which note BEST documents the nurse's call?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630460  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 34-year-old man with a closed fracture of the left femur is in skeletal traction on the orthopedic ward, 1 day after admission. The ward keeps a Kardex for each client and writes its nursing notes on paper.

The resident examines him at 03:15 and orders a different analgesic. Which note BEST documents the nurse's call?

## 보기

1. 03:00 Resident on duty called by phone about pain 9/10 and pale, cool left toes. Saw client 03:15; new analgesic ordered. **✔ 정답**
2. 03:00 Pain 9/10 and pale, cool left toes. Resident on duty is aware. New analgesic ordered at 03:15 after examination.
3. 03:00 Resident on duty called by phone about pain 9/10 and pale, cool left toes. Slow to respond but saw client at 03:15.
4. 03:00 Resident on duty called by phone about the client's worsening condition. Saw client at 03:15; new analgesic ordered.

**정답: 1**

## 해설

Documentation of a notification states who was notified, when and how, what was reported, and the response, including any orders. It is factual and free of opinions about colleagues.

## 심화 해설

Elements of documenting a notification
When a nurse notifies a physician about a change in a client's condition, the note must show who was notified, when and how, what was reported, and the response, including any orders received. The best note states that the resident on duty was called by phone at 03:00 about pain 9/10 and pale, cool left toes, saw the client at 03:15, and ordered a new analgesic. It is factual and contains no opinion about a colleague.

| Element | Option 1 | Option 2 | Option 3 | Option 4 |
| --- | --- | --- | --- | --- |
| Who and how | Resident, by phone | Is aware: no who or how | Resident, by phone | Resident, by phone |
| What was reported | Pain 9/10, pale cool toes | Findings listed | Pain 9/10, pale cool toes | Worsening condition: vague |
| Response and orders | Seen 03:15, new analgesic | New analgesic | Order missing | Seen 03:15, new analgesic |
| Objective tone | Yes | Yes | Slow to respond | Yes |

Why each distractor fails
Option 2 uses the phrase resident on duty is aware, which does not show who informed the resident, how, or when; it is a common but weak phrase in legal review. Option 3 includes slow to respond, a judgment about a colleague that does not belong in the record, and it leaves out the new order. Option 4 replaces the actual findings with worsening condition, which is too vague to show what the resident was told.

Why precise notification notes matter
The chart is a legal document. If the client's condition later worsens, the note must prove that the nurse recognized the change, reported specific findings to a named provider at a specific time, and received a response. Objective, specific language protects the client and the nurse. Concerns about a colleague's response are handled through the chain of command or an incident report, not written in the nursing notes.

Watch out! The note with the most information is not always the best. Option 3 has many details but adds an opinion and omits the order; the best note is complete and objective.

Exam takeaway
Key point! Document notifications as who, when, how, what was reported, and the response or orders, in objective language without opinions about colleagues.

## 임상 시나리오

Documenting a Physician NotificationWho, when, how, what, response
Best note: 03:00 resident on duty called by phone about pain 9/10 and pale, cool left toes. Saw client 03:15; new analgesic ordered.

Avoid vague phrases such as is aware or worsening condition; state the actual findings reported.

Leave out opinions such as slow to respond; concerns go through the chain of command.

## 핵심 개념

- **Notification note** — A chart entry recording that a provider was informed of a change, with time, method, content, and response.
- **Objective documentation** — Recording observed facts and actions without personal opinions or judgments.
- **Chain of command** — The formal line of authority used to escalate concerns about care.
- **Incident report** — An internal document reporting an unusual event, kept separate from the client's chart.

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