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 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.

A. "I need to set my hot water heater to 140 degrees Fahrenheit.". B. "I will apply tape over frayed areas of electrical cords.". C. "I need to have a fire escape plan with my family.". D. "I will use the grab bars when getting in and out of the bathtub.".

Correct Answer is ["C","D"]

Explanation

The correct answers are:

c."I need to have a fire escape plan with my family."
d."I will use the grab bars when getting in and out of the bathtub."

Rationale for each choice:

Choice c:

Having a fire escape plan is crucial for home safety. It ensures that all family members know what to do in the event of a fire, which can save valuable time and lives. Here's a detailed explanation of why a fire escape plan is essential:

Early Escape:A plan promotes quick evacuation,as everyone understands the escape routes and procedures.
Reduced Panic:Knowing what to do in a crisis minimizes panic and confusion,allowing for calmer and more efficient actions.
Accountability:The plan ensures that no one is left behind,especially children,older adults,or individuals with disabilities.
Firefighter Assistance:It provides vital information to firefighters,aiding their rescue efforts.
Regular Practice:Regularly practicing the plan familiarizes everyone with their roles and actions,ensuring smoother execution in a real fire.

Choice d:

Grab bars provide stability and support, reducing the risk of falls in bathrooms. Falls are a major safety hazard, especially for older adults, and can lead to serious injuries. Grab bars offer several benefits, including:

Entering and Exiting:They facilitate safe entry and exit from the bathtub or shower,especially on slippery surfaces.
Balance Support:They provide support when standing,reducing the likelihood of losing balance.
Transfer Assistance:They assist individuals with mobility impairments in safely transferring between the bathtub,shower,or toilet.
Confidence Boost:They offer a sense of security,allowing individuals to feel more confident and independent in the bathroom.

Rationale for incorrect choices:

Choice a:

Setting a hot water heater to 140 degrees Fahrenheit is unsafe. It can cause scalding burns within seconds, especially for children and older adults. The recommended temperature is 120 degrees Fahrenheit to balance safety and energy efficiency.

Choice b:

Taping over frayed electrical cords is a temporary and hazardous fix. It does not address the underlying issue of damaged wiring, which can lead to electrical shocks, fires, or electrocution. Frayed cords should be replaced immediately with new, undamaged ones.

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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

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Correct Answer is B

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Correct Answer is ["C","D"]

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