A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
Contraction of the left pupil when light shines in the right eye.
Basilar lung sounds that are diminished in the left lung.
Active bowel sounds in the lower right quadrant.
Capillary refill of 2 seconds in the lower right foot.
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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Correct Answer is C
Explanation
Choice A rationale
Eschar and slough are indicative of necrotic tissue and are not signs of proper healing. Eschar is a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite or other insect. Slough is a layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation. Both eschar and slough need to be removed for proper wound healing to occur.
Choice B rationale
Erythema and serosanguineous exudate can be present in the early stages of wound healing, but one week post-surgery, these signs may indicate inflammation or infection rather than proper healing. Erythema is redness of the skin caused by increased blood flow to the capillaries, often a sign of infection or irritation. Serosanguineous exudate is a thin, watery fluid that is slightly pink due to the presence of small amounts of blood, which can be normal immediately after surgery but should decrease over time.
Choice C rationale
A well-approximated incision site is a sign of proper healing. This means that the edges of the wound are close together and aligned, which promotes faster and more efficient healing. Proper approximation of the wound edges reduces the risk of infection and promotes the formation of a strong, healthy scar.
Choice D rationale
Beefy red granulation tissue is a sign of healing in open wounds, not in surgical incisions that are closed. Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. It is typically bright red or pink and indicates that the wound is healing from the inside out. However, in a surgical incision that is healing properly, the wound edges should be well approximated, and granulation tissue should not be visible.
Correct Answer is C
Explanation
Choice A rationale
A urine specific gravity of 1.015 is within the normal range and does not indicate dehydration. Dehydration typically results in a higher urine specific gravity due to the concentration of solutes in the urine.
Choice B rationale
A urine specific gravity of 1.005 is lower than normal and indicates dilute urine, which is not consistent with dehydration. Dehydration would result in more concentrated urine with a higher specific gravity.
Choice C rationale
A urine specific gravity of 1.035 indicates highly concentrated urine, which is consistent with dehydration. When a client has a history of vomiting and diarrhea, they are likely to be dehydrated, leading to a higher urine specific gravity.
Choice D rationale
A urine specific gravity of 1.025 is slightly higher than normal but not as high as 1.035. While it may indicate some level of concentration, it is not as indicative of severe dehydration as a specific gravity of 1.035.