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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Assisting with ambulation for a client who has a pulmonary infection.
Assistive personnel can perform basic nursing care functions such as assisting patients with mobility.
Choice A is wrong because showing a client how to use an incentive spirometer prior to surgery requires more specialized knowledge and training.
Choice C is wrong because irrigating a client’s infected surgical wound is a more complex medical procedure that should be performed by a licensed nurse.
Choice D is wrong because inserting a glycerin suppository for a client who is constipated is also a more complex medical procedure that should be performed by a licensed nurse.
Correct Answer is A
Explanation
According to a study published on PubMed, it is appropriate to change alimentation tubes and feeding bags every 72 hours rather than every 24 hours.
Choice B, Aspirate residual volume every 4 hr, is not necessary for continuous enteral feedings through a gastrostomy tube.
Choice C, Flush the tubing with 10 mL of water every 2 hr, is not necessary for continuous enteral feedings through a gastrostomy tube.
Choice D, Heat the formula to 40.5° C (105° F), is not necessary for continuous enteral feedings through a gastrostomy tube.
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