In a Charting by Exception (CBE) system, which scenario requires additional documentation?
A patient presents with sudden onset facial drooping and slurred speech
A patient reports no pain and demonstrates normal gait.
A patient has a blood pressure of 120/80 mmHg with no other changes.
A patient exhibits stable vital signs and no new symptoms.
The Correct Answer is A
A. A patient presents with sudden onset facial drooping and slurred speech: Charting by Exception focuses on documenting deviations from normal findings. Sudden facial drooping and slurred speech are abnormal and potentially indicative of a stroke or other urgent condition, requiring detailed documentation and prompt provider notification.
B. A patient reports no pain and demonstrates normal gait: Normal findings are considered expected and typically do not require additional documentation in a CBE system unless they change from baseline.
C. A patient has a blood pressure of 120/80 mmHg with no other changes: This is within normal limits and would not require additional notes, as CBE emphasizes abnormal or significant deviations.
D. A patient exhibits stable vital signs and no new symptoms: Stability and absence of symptoms reflect expected outcomes and are usually captured by the standard flow sheet in CBE, requiring no extra documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Respiratory rate measured at 22/min is observable, measurable, and obtained through direct assessment by the nurse. Objective data are factual findings that can be seen, heard, felt, or measured independently of the client’s perception.
B. Feeling anxious is a personal emotional experience described by the client. Subjective data rely on the client’s verbal report and cannot be directly measured or validated by the nurse.
C. Pain rated as 3 out of 10 reflects the client’s personal perception of discomfort. Although a scale is used, pain intensity is subjective because only the client can describe it.
D. Information provided by the partner is still based on reported experience rather than direct measurement by the nurse. This makes it subjective data, even though it comes from a secondary source.
Correct Answer is C
Explanation
A. Apply a topical ointment and continue with the bath: Applying ointment without further assessment or orders can mask skin changes and delay appropriate intervention. Early pressure injury management requires evaluation and interdisciplinary planning rather than routine topical treatment.
B. Cover the area with a bandage to prevent infection: Covering the area without assessment, staging, or provider notification may be inappropriate and could worsen skin breakdown. Dressing selection depends on the stage of the pressure injury and underlying skin integrity.
C. Document the findings and report to the healthcare provider: Redness over the sacral area may indicate a stage 1 pressure injury and requires prompt documentation and reporting. This allows for early interventions such as pressure redistribution, skin protection, and care plan updates before major damage occurs.
D. Ignore it since it is a common issue in bedridden clients: Pressure injuries are never expected or acceptable findings. Ignoring early signs increases the risk of progression to deeper tissue injury and serious complications.
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