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
Elevating the head of the bed to a 45-degree angle can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. However, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.
Choice B rationale
Lifting and locking the side rails in place ensures the safety of the client but does not directly address the client’s OSA or the potential respiratory depression associated with opioid analgesic administration.
Choice C rationale
Applying the client’s positive airway pressure device is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.
Choice D rationale
Removing dentures or other oral appliances may be necessary for client comfort and safety, but it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Determine client’s subjective measure of pain using a numerical pain scale. Assessing the client’s pain using a numerical pain scale allows the nurse to understand the client’s perception of their pain and to monitor changes over time. This is a crucial step in managing chronic pain as it provides a baseline for evaluating the effectiveness of interventions.
Choice B rationale
Implement a 24-hour schedule of routine administration of prescribed analgesic. Chronic pain management often requires a consistent and routine administration of analgesics to maintain a stable level of pain control. This approach helps to prevent the peaks and troughs of pain that can occur with as-needed dosing.
Choice C rationale
Assist the client to ambulate as much as possible during waking hours. While ambulation can be beneficial for some clients, it may not be appropriate for all clients with chronic pain, especially if the pain is severe or if ambulation exacerbates the pain. Therefore, this intervention should be individualized based on the client’s condition.
Choice D rationale
Provide comfort measures such as topical warm application and tactile massage. Non- pharmacological interventions such as warm applications and massage can help to alleviate pain and improve comfort. These measures can be used in conjunction with pharmacological treatments to provide a more comprehensive approach to pain management.
Choice E rationale
Encourage increased fluid intake and measure urinary output every 8 hours. While maintaining adequate hydration is important, this intervention is not directly related to the management of chronic pain. It may be more relevant for clients with other conditions such as renal issues.