A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
Basilar lung sounds that are diminished in the left lung.
Contraction of the left pupil when light shines in the right eye.
Capillary refill of 2 seconds in the lower right foot.
Active bowel sounds in the lower right quadrant.
The Correct Answer is A
Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.
In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”
Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.
Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.
Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A well-approximated incision means that the edges of the wound are close together and aligned properly, which is a sign that the surgical incision is healing properly.
Choice A is incorrect because eschar and slough in the wound are not signs of proper healing.
Choice B is incorrect because beety red granulation tissue is not a sign of proper healing.
Choice C is incorrect because erythema and serosanguineous drainage are not signs of proper healing.
Correct Answer is B
Explanation
Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences .
Choice A is not the answer because providing a physical demonstration may be helpful in teaching a skill, but it does not actively engage the clients in problem-solving .
Choice C is not the answer because incorporating verbal analogies can help clients understand concepts, but it does not actively engage them in problem-solving .
Choice D is not the answer because offering positive reinforcement can encourage and motivate clients, but it does not actively engage them in problem-solving .
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