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.

Answer and Explanation

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.

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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.

A. Shares the health history with case manager. B. Discusses diagnoses with the physical therapist. C. Provides a list of food allergies to nutritional services. D. Requests military records by phone.

Correct Answer is D

Explanation

Requesting military records by phone without the patient’s consent would be a breach of confidentiality.

Choice A is incorrect because sharing the health history with a case manager who is involved in the patient’s care would not be a breach of confidentiality.

Choice B is incorrect because discussing diagnoses with a physical therapist who is involved in the patient’s care would not be a breach of confidentiality.

Choice C is incorrect because providing a list of food allergies to nutritional services who are involved in the patient’s care would not be a breach of confidentiality.

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

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