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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Beginning with questions that are less sensitive in nature helps build rapport and makes the client more comfortable. This approach gradually leads to more sensitive topics, reducing anxiety and promoting honest responses.
Choice B rationale
Getting the most difficult questions over with first can increase the client’s anxiety and discomfort, leading to less honest or incomplete answers. It is not an effective strategy for sensitive topics.
Choice C rationale
Sharing personal values to put the client at ease can introduce bias and affect the client’s responses. It is important to remain neutral and nonjudgmental.
Choice D rationale
Asking questions in a vague, non-specific format can lead to misunderstandings and incomplete information. Clear, direct questions are more effective for gathering accurate information.
Correct Answer is D
Explanation
Choice A rationale
Lubricating the thermometer before inserting it into the ear is not a standard practice for using a tympanic thermometer. Tympanic thermometers are designed to be used without lubrication, and using lubrication could interfere with the accuracy of the reading.
Choice B rationale
Holding the thermometer in place for a full three minutes is unnecessary for tympanic thermometers. These thermometers provide quick readings, usually within a few seconds, and holding it for longer does not improve accuracy.
Choice C rationale
Pulling the client’s auricle down and back is the correct technique for infants and young children. For adults, the correct technique is to pull the auricle up and back to straighten the ear canal for an accurate reading.
Choice D rationale
Using positive reinforcement to affirm that the procedure is being performed correctly is the appropriate action. The UAP is using the correct technique by pulling the client’s auricle up and back, which is the proper method for adults.