Which assessment should the nurse document when charting by exception?
Active bowel sounds in the lower right quadrant.
Contraction of the left pupil when light shines in the right eye.
Basilar lung sounds that are diminished in the left lung.
Capillary refill of 2 seconds in the lower right foot.
The Correct Answer is C
Choice A rationale
Active bowel sounds in the lower right quadrant are a normal finding and do not deviate from the established norm or expected outcome. Therefore, they do not need to be documented when charting by exception.
Choice B rationale
Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response. This is an expected finding and does not need to be documented when charting by exception.
Choice C rationale
Basilar lung sounds that are diminished in the left lung are not within normal limits and deviate from the expected outcome. This abnormal finding should be documented when charting by exception.
Choice D rationale
Capillary refill of 2 seconds in the lower right foot is a normal finding and does not deviate from the established norm or expected outcome. Therefore, it does not need to be documented when charting by exception.
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Correct Answer is D
Explanation
Choice A rationale
Placing the client on contact precautions is not indicated based on the provided orders. Contact precautions are typically used for infections that are spread by direct or indirect contact, such as MRSA or C. difficile. The orders do not suggest the presence of such an infection.
Choice B rationale
Starting a high-fiber diet is not indicated. The client is already on a regular diet, and there is no mention of conditions that would necessitate a high-fiber diet, such as constipation or diverticulosis.
Choice C rationale
Administering an oral steroid is not indicated. The orders include Cefazolin, an antibiotic, and Metformin, an antidiabetic medication. There is no indication for an oral steroid, which is typically used for inflammatory conditions or autoimmune diseases.
Choice D rationale
Making the client NPO (nothing by mouth) is the correct action. This is likely due to the need for accurate blood glucose monitoring and the administration of IV antibiotics. Being NPO ensures that the client does not eat or drink anything that could interfere with these treatments.
Correct Answer is B
Explanation
Choice A rationale
Administering the medication to a client behind a closed curtain may provide privacy but does not address the ethical and legal implications of administering medication without proper consent or informing the client of the medication’s true nature.
Choice B rationale
Informing a client that the medication being administered is a vitamin is deceptive and unethical. It violates the principle of informed consent, which requires that patients be fully informed about the medications they are receiving, including their purpose and potential side effects.
Choice C rationale
Placing a client in restraints without a healthcare provider’s order is a violation of patient rights and can be considered an assault. Restraints should only be used when absolutely necessary and with proper authorization to ensure the safety of the patient and staff.
Choice D rationale
Enlisting security personnel to assist with restraining the client may be necessary in some situations to ensure safety. However, it should be done following proper protocols and with the appropriate orders from a healthcare provider.