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 A

Explanation

The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.

This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.

Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.

Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.

Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.

A. "Tell me about the visit with your significant other. I can see that you are feeling lonely." B. "I noticed that you were more insulting to the evening group after your significant other left. Why is that?" C. "Why don't you try to make some friends here so you won't feel so lonely?" D. "It sounds like your visit with your significant other was important to you. How did it go?" E. None F. None

Correct Answer is D

Explanation

Choice D
This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.

Choice A is not the correct answer because it assumes that the client is feeling lonely without giving them the opportunity to express their own feelings.

Choice B is not the correct answer because it confronts the client about their behavior in an accusatory manner.

Choice C is not the correct answer because it suggests a solution without first exploring the client’s feelings and needs.

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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

A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Correct Answer is A

Explanation

Which of the following responses would be the most therapeutic when communicating with a client who has recently had a visit from their significant other and is displaying changes in behavior?

Correct Answer is D

Explanation

Which response by the nurse is most therapeutic?

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