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 C

Explanation

A. 3 mL syringe and a sterile needle.
This is incorrect. A sterile needle is unnecessary for administering an oral medication. Syringes with needles are used for injections, not for measuring or delivering oral medications.

B. One ounce medicine cup.
This is incorrect. While a medicine cup can be used for liquid medications, it is not precise for small volumes such as 2 mL. The graduations on a medicine cup are typically in larger increments, making it difficult to measure accurately.

C. 3 mL syringe.
This is correct. A 3 mL syringe is precise and suitable for measuring a 2 mL dose of a viscous liquid. Syringes provide clear markings, ensuring accurate measurement of small volumes. Additionally, the absence of a needle makes it appropriate for oral administration.

D. Tuberculin syringe.
This is incorrect. Although a tuberculin syringe can accurately measure small doses, it is designed for very small volumes, such as 1 mL or less. A 3 mL syringe is more appropriate for a 2 mL dose.

A. "Tell me about the visit with your significant other. B. I can see that you are feeling lonely." C. "I noticed that you were more insulting to the evening group after your significant other left. D. Why is that?" E. "Why don't you try to make some friends here so you won't feel so lonely?"

Correct Answer is D

Explanation

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

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Explanation

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Correct Answer is D

Explanation

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