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

Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client’s vital signs.

This includes checking the client’s blood pressure, pulse rate, respiratory rate, and temperature.

These measurements can provide important information about the client’s overall health status and can help the nurse determine if it is safe to proceed with the procedure.

Choice A is not correct because abdominal girth is not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.

Choice B is not correct because breath sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.

Choice C is not correct because bowel sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.

A. Positive external places. B. Motivational phrases. C. Tranquil sounds. D. Emotional reflection.

Correct Answer is A

Explanation

Guided imagery involves creating a specific imagined reality for yourself.

These techniques can be self-taught or guided by a professional.

The more you’re able to use your imagination and engage your senses, the greater the benefits 1.

Choice B is not the answer because motivational phrases may not be as effective as positive external places in reducing chronic pain through guided imagery.

Choice C is not the answer because tranquil sounds may not be as effective as positive external places in reducing chronic pain through guided imagery.

Choice D is not the answer because emotional reflection may not be as effective as positive external places in reducing chronic pain through guided imagery.

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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

Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?

Correct Answer is D

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. What should the nurse direct the client's attention on during the session?

Correct Answer is A

Explanation

The nurse is caring for a male client with decreased circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry the feet. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

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