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 B
Explanation
This is the nurse’s priority intervention for a client undergoing a total laryngectomy because it is important for the client to understand how to use an artificial larynx to communicate after the surgery.
Choice A is wrong because explaining the techniques of esophageal speech is not the priority intervention for a client undergoing a total laryngectomy.
Choice C is wrong because determining the client’s reading ability is not the priority intervention for a client undergoing a total laryngectomy.
Choice D is wrong because scheduling a support session for the client is not the priority intervention for a client undergoing a total laryngectomy.
Correct Answer is C
Explanation
If a client expresses confusion or lack of understanding about a medical procedure, the nurse should notify the provider so that they can clarify any misunderstandings and ensure that the client is fully informed before giving their consent.
Choice A is wrong because providing brochures about the procedure may not be sufficient to address the client’s confusion or lack of understanding.
Choice B is wrong because completing an incident report is not an appropriate action in this situation.
Choice D is wrong because it is the provider’s responsibility to ensure that the client fully understands the procedure and gives informed consent.
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