Which assessment should the nurse document when charting by exception?

Active bowel sounds in the lower right quadrant.

Contraction of the left pupil when light shines in the right eye.

Basilar lung sounds that are diminished in the left lung.

Capillary refill of 2 seconds in the lower right foot.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Active bowel sounds in the lower right quadrant are a normal finding and do not deviate from the established norm or expected outcome. Therefore, they do not need to be documented when charting by exception.
Choice B rationale
Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response. This is an expected finding and does not need to be documented when charting by exception.
Choice C rationale
Basilar lung sounds that are diminished in the left lung are not within normal limits and deviate from the expected outcome. This abnormal finding should be documented when charting by exception.
Choice D rationale
Capillary refill of 2 seconds in the lower right foot is a normal finding and does not deviate from the established norm or expected outcome. Therefore, it does not need to be documented when charting by exception.

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Correct Answer is C

Explanation

Choice A rationale
Removing dentures or other oral appliances may help prevent airway obstruction but is not the most critical intervention for a client with severe obstructive sleep apnea (OSA)4.
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention to maintain airway patency and prevent respiratory compromise in a client with severe obstructive sleep apnea (OSA)4.
Choice D rationale
Putting and locking the side rails in place is important for safety but does not directly address the airway management needs of a client with severe obstructive sleep apnea (OSA)4.

A. Wears gloves to dispose of the needle and syringe. B. Dons a face mask before administering the medication. C. Washes hands before handling the needle and syringe. D. Removes the needle before discarding used syringes.

Correct Answer is C

Explanation

Choice A rationale
Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it is not the primary action that indicates an understanding of standard precautions. Standard precautions emphasize hand hygiene as the most critical step in preventing infection transmission.
Choice B rationale
Donning a face mask before administering the medication is not necessary for standard precautions in home settings. Face masks are typically used in healthcare settings to prevent the spread of respiratory infections, but they are not required for routine medication administration at home.
Choice C rationale
Washing hands before handling the needle and syringe is a fundamental aspect of standard precautions. Hand hygiene is the most effective way to prevent the spread of infections and is a critical step in ensuring safe injection practices.
Choice D rationale
Removing the needle before discarding used syringes is not recommended. The entire needle and syringe should be disposed of in a sharps container to prevent needlestick injuries and contamination.

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Which assessment should the nurse document when charting by exception?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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