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 B

Explanation

Choice A rationale
Administering PRN oral pain medication without further assessment may not be appropriate. The nurse needs to understand the cause of the grimacing before intervening with medication.
Choice B rationale
Asking the client what is causing the grimacing is the first step. This allows the nurse to gather more information and understand the client’s experience, which is essential for appropriate intervention.
Choice C rationale
Monitoring the client’s nonverbal behavior is important but should follow the initial assessment. Understanding the cause of the grimacing takes priority.
Choice D rationale
Reviewing the pain medications prescribed is a necessary step but should come after assessing the client’s current pain status and understanding the cause of the grimacing.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain, the client denies having any pain. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Correct Answer is C

Explanation

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?

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The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?