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

Neutrophils are a type of white blood cell that play a key role in fighting infections.

An elevated neutrophil count can indicate the presence of an infection.

Therefore, before reporting the finding of a red, tender, and swollen wound at the site of the lesion to the healthcare provider, the nurse should note the client’s neutrophil count.

Choice A is not correct because hematocrit is not the laboratory value that the nurse should note before reporting the finding to the healthcare provider.

Choice B is not correct because serum is not a laboratory value.

Choice C is not correct because blood PT level is not the laboratory value that the nurse should note before reporting the finding to the healthcare provider.a

A. Obtain a do not resuscitate prescription. B. Set up a family conference to discuss the client's wishes. C. Discuss with the client her meaning of heroic measures. D. Consult the palliative care team about the client's care.

Correct Answer is C

Explanation

The nurse should first discuss with the client her meaning of heroic measures.

This will help the nurse to understand the client’s wishes and preferences for her care.

Choice A is incorrect because obtaining a do not resuscitate prescription should be done after discussing the client’s wishes and preferences.

Choice B is incorrect because setting up a family conference to discuss the client’s wishes should be done after discussing the client’s wishes and preferences with her.

Choice D is incorrect because consulting the palliative care team about the client’s care should be done after discussing the client’s wishes and preferences with her.

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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

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is D

Explanation

An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops. What actions should the nurse take first?

Correct Answer is C

Explanation

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