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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Free Nursing Study Resources

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. Administer each medication at the same time to ensure pain relief. B. Administer the medication with the highest dose first, then the others. C. Administer the medications as ordered based on the client's pain level. D. Administer the medication with the longest duration of action

Correct Answer is C

Explanation

The most important intervention the nurse should take when administering these medications to the client is to assess the client’s pain level and administer the appropriate medication based on the level of pain.

Choice A is not the correct answer because administering all medications at the same time may not provide effective pain relief and could result in overmedication.

Choice B is not the correct answer because administering the medication with the highest dose first may not provide effective pain relief and could result in overmedication.

Choice D is not the correct answer because administering the medication with the longest duration of action first may not provide immediate pain relief.

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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

A postoperative client has been prescribed three different analgesics for different levels of pain. What is the most important intervention the nurse should take when administering these medications to the client?

Correct Answer is C

Explanation

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL". How many tablespoons should the nurse instruct the client to take within each dose? (Enter numerical value only).

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