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 B

Explanation

To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus.

Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.

Choice A is not the answer because tapping the feet forwards and backwards exercises the ankle joint, which is not a hinge joint.

Choice C is not the answer because turning the head to the right and left exercises the pivot joint in the neck, which is not a hinge joint.

Choice D is not the answer because extending the arm at the side and rotating in circles exercises the ball-and-socket joint in the shoulder, which is not a hinge joint.

A. "I'm sorry but your son's medical information is none of your business.". B. "The healthcare provider will share this information with you.". C. "I can only give medical information to your son because he is an adult.". D. "I will get these results back from the lab as soon as possible.".

Correct Answer is C

Explanation

The best response for the nurse to provide is “I can only give medical information to your son because he is an adult.” Since the client is 19 years old and considered an adult, the nurse must respect the client’s right to privacy and confidentiality.

Choice A is not the answer because it is rude and unprofessional.

Choice B is not the answer because it does not address the issue of privacy and confidentiality.

Choice D is not the answer because it does not address the issue of privacy and confidentiality.

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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

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Correct Answer is B

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Correct Answer is C

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