A healthcare organization requires nurses to chart by exception.

Which assessment should the nurse document?

Active bowel sounds in the lower right quadrant.

Contraction of the left pupil when light shines in the right eye.

Basilar lung sounds that are diminished in the left lung.

Capillary refill of 2 seconds in the lower right foot.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Active bowel sounds in the lower right quadrant are a normal finding and do not deviate from the established norm or expected outcome. Therefore, they do not need to be documented when charting by exception.
Choice B rationale
Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response. This is an expected finding and does not need to be documented when charting by exception.
Choice C rationale
Basilar lung sounds that are diminished in the left lung are not within normal limits and deviate from the expected outcome. This abnormal finding should be documented when charting by exception.
Choice D rationale
Capillary refill of 2 seconds in the lower right foot is a normal finding and does not deviate from the established norm or expected outcome. Therefore, it does not need to be documented when charting by exception.

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Correct Answer is ["A","C","E","G"]

Explanation

Choice A rationale
Measuring vital signs at 0800 is a standard practice in many healthcare settings to establish a baseline for the day.
Choice B rationale
Measuring vital signs at 1000 is not typically a standard time unless there is a specific clinical indication.
Choice C rationale
Measuring vital signs at 1200 helps monitor the client’s status around midday and can be important for assessing the effects of morning medications or treatments.
Choice D rationale
Measuring vital signs at 1400 is not typically a standard time unless there is a specific clinical indication.
Choice E rationale
Measuring vital signs at 1600 helps monitor the client’s status in the afternoon and can be important for assessing the effects of afternoon medications or treatments.
Choice F rationale
Measuring vital signs at 1800 is not typically a standard time unless there is a specific clinical indication.
Choice G rationale
Measuring vital signs at 2000 helps monitor the client’s status in the evening and can be important for assessing the effects of evening medications or treatments.

A. Remove dentures or other oral appliance. B. Elevate the head of the bed to a 45-degree angle. C. Apply the client’s positive airway pressure device. D. Put and lock the side rails in place.

Correct Answer is C

Explanation

Choice A rationale
Removing dentures or other oral appliances may help prevent airway obstruction but is not the most critical intervention for a client with severe obstructive sleep apnea (OSA)4.
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention to maintain airway patency and prevent respiratory compromise in a client with severe obstructive sleep apnea (OSA)4.
Choice D rationale
Putting and locking the side rails in place is important for safety but does not directly address the airway management needs of a client with severe obstructive sleep apnea (OSA)4.

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A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What times should the nurse measure vital signs? Select all that apply.

Correct Answer is ["A","C","E","G"]

Explanation

Which intervention is most important for the nurse to implement before leaving a postoperative client with severe obstructive sleep apnea (OSA) alone?

Correct Answer is C

Explanation

A family requested a visit from a hospice nurse as they think the client appears to be nearing the end of life. The nurse assesses the client. Which of the following signs indicate that the client is near death?

To assess the quality of the client’s abdominal pain, which approach should the nurse use?

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Which intervention should the nurse include in the plan of care for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a fort?

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

A healthcare organization requires nurses to chart by exception.

Which assessment should the nurse document?