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
A nurse can delegate the task of performing a simple dressing change to an assistive personnel.
Delegation is an essential nursing skill that allows a qualified healthcare worker, like an RN, to transfer routine and low-risk duties to nursing assistive personnel.
This frees up the RN’s time to address more pressing matters, including critical patients and tasks.
Choice A is wrong because changing IV tubing is not a task that can be delegated to assistive personnel.
Choice C is wrong because inserting an NG tube is not a task that can be delegated to assistive personnel.
Choice D is wrong because evaluating the healing of an incision is not a task that can be delegated to assistive personnel.
These tasks require the expertise and training of a licensed nurse.
Correct Answer is B
Explanation
It is recommended that IVs are placed in the arm on the opposite side of your surgery, if possible.
Choice A is wrong because it involves placing the IV catheter on the same side as the mastectomy.
Choice C is wrong because it involves placing the IV catheter on the same side as the mastectomy.
Choice D is wrong because it involves placing the IV catheter on a vein that is not commonly used for IV therapy.
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