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

A.

Contraction of the left pupil when light shines in the right eye.

B.

Basilar lung sounds that are diminished in the left lung.

C.

Active bowel sounds in the lower right quadrant.

D.

Capillary refill of 2 seconds in the lower right foot.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response and does not need to be documented in charting by exception. This finding is within normal limits and does not indicate any deviation from the expected outcome.

 

Choice B rationale

 

Basilar lung sounds that are diminished in the left lung should be documented because this finding deviates from the normal lung sounds and indicates a potential issue that needs further investigation. Charting by exception focuses on documenting abnormalities or deviations from the norm.

 

Choice C rationale

 

Active bowel sounds in the lower right quadrant are a normal finding and do not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.

 

Choice D rationale

 

Capillary refill of 2 seconds in the lower right foot is a normal finding and does not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response and does not need to be documented in charting by exception. This finding is within normal limits and does not indicate any deviation from the expected outcome.

Choice B rationale

Basilar lung sounds that are diminished in the left lung should be documented because this finding deviates from the normal lung sounds and indicates a potential issue that needs further investigation. Charting by exception focuses on documenting abnormalities or deviations from the norm.

Choice C rationale

Active bowel sounds in the lower right quadrant are a normal finding and do not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.

Choice D rationale

Capillary refill of 2 seconds in the lower right foot is a normal finding and does not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.

Correct Answer is A

Explanation

Choice A rationale

Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct technique for subcutaneous heparin injections. This reduces the risk of injury to blood vessels and nerves and ensures consistent absorption of the medication.

Choice B rationale

Rotating injections between the abdomen and gluteal areas is not recommended for low molecular weight heparin (LMWH) injections. The abdomen is the preferred site for consistent absorption.

Choice C rationale

Massaging the injection site to increase absorption is not recommended for LMWH injections. Massaging can cause bruising and affect the absorption of the medication.

Choice D rationale

Expelling the air in the prefilled syringe prior to injection is not recommended for LMWH injections. The air bubble helps ensure the entire dose is administered and prevents medication from leaking out.

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