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 A
Explanation
Choice A rationale
Smoking cessation is the most important lifestyle modification for preventing and managing cardiac disease. Smoking is a major modifiable risk factor that can cause atherosclerosis, hypertension, arrhythmias, thrombosis, and myocardial infarction. Quitting smoking has a more direct effect on improving the function and structure of the blood vessels and heart, significantly reducing the risk of cardiovascular events and mortality.
Choice B rationale
A low-fat diet is a useful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While it helps in lowering cholesterol levels and reducing inflammation, smoking cessation has a stronger influence on overall cardiovascular health.
Choice C rationale
Stress reduction is a helpful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Although managing stress can improve heart health, smoking cessation has a more immediate and significant impact on reducing cardiovascular risks.
Choice D rationale
Regular exercise is beneficial for preventing and managing cardiac disease, but it is not the most important lifestyle modification. Exercise helps in maintaining a healthy weight, lowering blood pressure, and improving overall cardiovascular health, but smoking cessation has a greater impact on reducing the risk of cardiovascular events.
Correct Answer is D
Explanation
Choice A rationale
Adhering to the medication regimen is important, but it does not specifically address the client’s ability to self-administer insulin, which is crucial for managing hyperglycemia post- discharge.
Choice B rationale
Auscultating breath sounds every 4 hours is important for monitoring respiratory status but does not address the client’s need to manage their diabetes through self-injection of insulin.
Choice C rationale
Demonstrating the ability to change the ostomy bag is important for postoperative care but does not address the specific need for managing hyperglycemia through insulin self- administration.
Choice D rationale
Ensuring the client can self-administer insulin injections before discharge is crucial for managing their hyperglycemia and maintaining their health post-discharge.