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

Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive.

A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed 1.

Choice A is not the answer because asking questions in a vague, nonspecific format can lead to confusion and misunderstanding.

Choice B is not the answer because getting the most difficult questions over with first can be overwhelming for the client.

Choice D is not the answer because sharing personal values may not put the client at ease and may even make them feel uncomfortable.

A. Places food on the unaffected side of the mouth. B. Raises the head of the bed to 80 degrees. C. Positions the head with the chin tilted slightly downward. D. Allows 30 minutes of rest before feeding.

Correct Answer is B

Explanation

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

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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 caring for a client who has only months predicted to live. The client avoids questions regarding plans for care. What is the next approach for the nurse to use when discussing end of life issues with the client?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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