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.".

Answer and Explanation

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.

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Correct Answer is A

Explanation

Thirst is a common symptom of hyperglycemia, or high blood sugar, in clients with diabetes mellitus.
Choice B is wrong because confusion can be a symptom of both hyperglycemia and hypoglycemia (low blood sugar).
Choice C is wrong because shakiness is more commonly associated with hypoglycemia.
Choice D is wrong because cool skin is not a common symptom of hyperglycemia.

A. Change the tubing set every 72 hr. B. Aspirate residual volume every 4 hr. C. Flush the tubing with 10 mL of water every 2 hr. D. Heat the formula to 40.5° C (105° F).

Correct Answer is B

Explanation

A. Change the tubing set every 72 hr:Continuous enteral feeding tubing sets should generally be changed every 24 hours to reduce the risk of bacterial contamination. Changing every 72 hours is too long and increases infection risk.

B. Aspirate residual volume every 4 hr:Aspiration of residual volume every 4 hours is standard practice when providing continuous enteral feedings. This ensures the client is tolerating the feedings and helps prevent aspiration or overfeeding. Large residual volumes may indicate poor gastric emptying.

C. Flush the tubing with 10 mL of water every 2 hr:The tubing should be flushed with 30 mL of water every 4-6 hours (depending on protocol), not just 10 mL, to maintain tube patency and prevent clogging.

D. Heat the formula to 40.5° C (105° F):Formula should not be heated to such a high temperature. It should be administered at room temperature to avoid discomfort and potential damage to the gastrointestinal tract.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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