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 C

Explanation

When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time.
This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.

A. The client's skin on the lower back is intact without redness. B. The client states that he is able to concentrate while reading. C. The client's vital signs are within the expected reference range. D. The client is laughing at a television show.

Correct Answer is A

Explanation

This indicates that the compress has been effective in relieving lower back pain and has not caused any skin irritation or damage.
Choice B is wrong because the ability to concentrate while reading is not directly related to the effectiveness of a warm, moist compress for relieving lower back pain.
Choice C is wrong because vital signs being within the expected reference range does not necessarily indicate that the compress has been effective in relieving lower back pain.
Choice D is wrong because laughing at a television show does not necessarily indicate that the compress has been effective in relieving lower back pain.

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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

When caring for a client who has wrist restraints after an episode of violent behavior, which of the following actions should the nurse take?

Correct Answer is C

Explanation

When caring for a client who is receiving a warm, moist compress to relieve lower back pain, which of the following findings should indicate to the nurse that the compress has been effective?

Correct Answer is A

Explanation

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