A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?
"No changes noted to the wound from previous nursing notes.".
"New dressing applied as prescribed; no drainage on old dressing.".
"The wound seems clean and does not appear to be infected.".
"Client premedicated with MSO4 subq prior to dressing change.".
The Correct Answer is B
The nurse’s entry “New dressing applied as prescribed; no drainage on old dressing” demonstrates correct documentation because it includes specific details about the wound and the dressing change.
Choice A is wrong because it does not provide specific details about the wound or the dressing change.
Choice C is wrong because it includes subjective language (“seems” and “does not appear”) rather than objective observations.
Choice D is wrong because it only documents medication administration and does not provide any information about the wound or the dressing change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A full liquid diet includes all foods that are liquid or will turn to liquid at room temperature or melt at body temperature.
It gives you more nutrition than a clear liquid diet.
Plain yogurt is a food that can be included in a full-liquid diet.
Choice B is not the answer because oatmeal is not part of a full-liquid diet.
Choice C is not the answer because applesauce is not part of a full-liquid diet.
Choice D is not the answer because scrambled eggs are not part of a full-liquid diet.
Correct Answer is B
Explanation
The nurse should respond to the client’s concern by saying “You are worried about having to wear a colostomy bag?” This response acknowledges the client’s concern and allows the client to express their feelings and concerns about the potential colostomy.
Choice A is not an appropriate response because it dismisses the client’s current concern and delays addressing it until after the surgery.
Choice C is not an appropriate response because it does not address the client’s concern about wearing a colostomy bag.
Choice D is not an appropriate response because it shifts the focus away from the client’s concern and onto someone else.
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