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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client has difficulty sleeping due to obstructive sleep apnea (OSA), and using a positive airway pressure device can help keep their airway open and prevent dangerous pauses in breathing while they sleep 1.
Choice A is not the answer because elevating the head of the bed to a 45-degree angle may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.
Choice C is not the answer because lifting and locking the side rails in place is a safety measure but does not directly address the client’s OSA 1.
Choice D is not the answer because removing dentures or other oral appliances may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.
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.
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