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
The client is dehydrated. Dehydration typically results in concentrated, dark yellow urine. Clear, yellow urine indicates that the client is well-hydrated and not dehydrated. Dehydration would cause the urine to be more concentrated and darker in color due to the reduced volume of water in the body.
Choice B rationale
The client has a urinary tract infection. A urinary tract infection (UTI) often causes urine to appear cloudy, foul-smelling, or tinged with blood. Clear, yellow urine is not indicative of a UTI. UTIs are usually associated with symptoms such as pain or burning during urination, frequent urination, and cloudy or bloody urine.
Choice C rationale
The client has normal urine output. Clear, yellow urine is a sign of normal urine output and indicates that the client is well-hydrated. Normal urine color ranges from pale yellow to amber, depending on the concentration of the urine. Clear, yellow urine suggests that the client is drinking an adequate amount of water and maintaining proper hydration.
Choice D rationale
The client has kidney stones. Kidney stones can cause urine to appear cloudy, pink, red, or brown due to the presence of blood. Clear, yellow urine is not indicative of kidney stones. Symptoms of kidney stones include severe pain in the back or side, blood in the urine, and frequent urination. Clear, yellow urine suggests that the client does not have kidney stones.

A. The client will demonstrate the ability to change the ostomy bag in two days. B. The client attempts to self-administer insulin but is unable to perform the injection. C. The client’s breath sounds will be auscultated by the nurse every 4 hours. D. The client will adhere to the medication regimen after discharge.

Correct Answer is D

Explanation

Choice A rationale
This outcome statement focuses on the client’s ability to perform a specific task related to ostomy care. While it’s important for clients with a colostomy to learn how to change their ostomy bag, in the context of this scenario, where the client has developed hyperglycemia requiring insulin injections, the priority lies in managing their diabetes and adhering to the medication regimen. Therefore, while ostomy care is important, it may not be the most immediate concern.
Choice B rationale
This outcome statement indicates the client’s attempt to self-administer insulin but inability to perform the injection. While it’s important for clients to be able to self-administer insulin, the emphasis in this scenario should be on ensuring that the client adheres to the medication regimen, rather than focusing solely on their ability to self-administer insulin immediately after discharge. Therefore, while self-administration of insulin is relevant, it may not be the most immediate priority in the postoperative plan of care.
Choice C rationale
This outcome statement focuses on monitoring the client’s respiratory status by auscultating breath sounds at regular intervals. While respiratory assessment is important, especially postoperatively, it may not directly address the client’s primary health concern in this scenario, which is managing hyperglycemia and insulin administration.
Choice D rationale
This outcome statement directly addresses the client’s need to manage their hyperglycemia by adhering to the prescribed insulin regimen. Given that the client has developed hyperglycemia requiring insulin injections, ensuring medication adherence is crucial for controlling blood sugar levels and preventing complications associated with uncontrolled diabetes. This choice aligns with the client’s health needs and goals following the surgical procedure and the development of hyperglycemia.

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Which assessment should the nurse document when charting by exception?

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Naxlex Comprehensive Predictor Exams

A client voided clear, yellow urine.

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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