Practice Question
In assessing the skin condition of an elderly client, the nurse notes that, over the sacral area, there is a 2-cm to 3-cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be:
Answer Choices:
Correct Answer:
"2-cm to 3-cm reddened area on sacrum with open center. Does not blanch."
Rationale:
🔴 Provides accurate size measurement of the lesion (2–3 cm).
🔴 Describes color and non-blanching to indicate tissue compromise.
🔴 Notes that the center is open, specifying stage II pressure ulcer characteristics.
🔴 Avoids subjective terms such as “massaged” which can be misleading.
🔴 Documentation is clear, concise, and objective, essential for care planning and legal record.
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This question is from Communication, Pharmacology, Tissue Integrity Exam 2 which contains 70 questions.
More Questions from This Exam
A 2-year-old child is hospitalized with tonsillitis and bilateral otitis media. The nurse is preparing to administer prescribed ear drops. When instilling the medication, the nurse should pull the child's earlobe?
Answer Choices:
A. Straight outward.
B. Up and outward.
C. Up and back.
D. Down and back.
The nurse is talking a verb order for a new medication. Which is the most accurate and safest way for the nurse to transcribe an order for a two milligram dose into the client's chart?
Answer Choices:
A. 2 mg
B. Two mg
C. 2.0 mg
D. two milligrams
A nurse is preparing to administer iron, a medication that has the potential to stain the skin. Which of the following should the nurse do?
Answer Choices:
A. Administer the medication subcutaneously due to lack of blood flow.
B. Administer the medication via Z-track.
C. Contact the healthcare provider to change the route of the medication.
D. Prepare the medication for dorsal gluteal administration.
The pediatric nurse knows the most accurate medication dosage for a child is determined by using which piece of assessment data:
Answer Choices:
A. the child's BMI
B. the child's weight
C. the child's height
D. the child's developmental stage
Which of the following examples best demonstrates safe drug administration by the nurse?
Answer Choices:
A. Leaving the medications on the bedside stand after verifying client identification
B. Returning unused portion of a medication to a stock supply bottle
C. Administering an oral medication with the client sitting upright
D. Asking a small child to say their name before administering the medication
From Exam
Communication, Pharmacology, Tissue Integrity Exam 2
70 Questions
View Full Exam Start PracticingQuestion Details
- Category: RN Nursing Exam(s)
- Subcategory: General Exams
- Domain: 🚑Pharmacology
- Answer Choices: 4