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
Recording the client’s daily weight is not the most immediate concern for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The priority is to address the client’s comfort and hydration.
Choice B rationale
Maintaining the client in high Fowler’s position may help with breathing but does not directly address the issue of dry mucous membranes.
Choice C rationale
Keeping mucous membranes moist is crucial for the comfort of a terminally ill client who is mouth breathing and refusing anything to eat or drink. This intervention helps prevent dryness and discomfort.
Choice D rationale
Reporting any change in urine color is important but not the most immediate concern for a terminally ill client in this condition. The priority is to address the client’s comfort and hydration.

A. Administering the medication to a client behind a closed curtain. B. Informing a client that the medication being administered is a vitamin. C. Placing a client in restraints without having a healthcare provider’s order. D. Enlisting security personnel to assist with restraining the client.

Correct Answer is B

Explanation

Choice A rationale
Administering the medication to a client behind a closed curtain may provide privacy but does not address the ethical and legal implications of administering medication without proper consent or informing the client of the medication’s true nature.
Choice B rationale
Informing a client that the medication being administered is a vitamin is deceptive and unethical. It violates the principle of informed consent, which requires that patients be fully informed about the medications they are receiving, including their purpose and potential side effects.
Choice C rationale
Placing a client in restraints without a healthcare provider’s order is a violation of patient rights and can be considered an assault. Restraints should only be used when absolutely necessary and with proper authorization to ensure the safety of the patient and staff.
Choice D rationale
Enlisting security personnel to assist with restraining the client may be necessary in some situations to ensure safety. However, it should be done following proper protocols and with the appropriate orders from a healthcare provider.

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Which assessment should the nurse document when charting by exception?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention should the nurse include in the plan of care for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink?

Correct Answer is C

Explanation

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a fort?

Correct Answer is B

Explanation

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

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