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 A
Explanation
It is important for the UAP to receive proper education and training on how to care for a foot ulcer before being assigned to care for a client with this condition.
Choice B is not correct because advising the UAP to wear gloves when caring for the FP is not the first action the nurse should take.
Choice C is not correct because instructing the UAP to start with basic wound care precautions is not the first action the nurse should take.
Choice D is not correct because asking the UAP which action they would take first and stating why is not the first action the nurse should take.
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
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