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
Determining the client’s activity tolerance is important but should follow the initial assessment of the client’s ability to perform ADLs safely.
Choice B rationale
Teaching the client to shorten the stride to prevent falls is not necessary if the client’s gait is smooth and steady. This intervention is more appropriate for clients with gait instability.
Choice C rationale
Initiating a fall risk protocol for the client is not necessary if the client’s gait is smooth and steady. This protocol is more appropriate for clients with a higher risk of falls.
Choice D rationale
Recording the client’s ability to perform ADLs safely is the next appropriate action. This documentation is essential for the care plan and ensures that the client’s current status is accurately reflected.
Correct Answer is B
Explanation
Choice A rationale
Administering PRN oral pain medication without further assessment may not be appropriate. The nurse needs to understand the cause of the grimacing before intervening with medication.
Choice B rationale
Asking the client what is causing the grimacing is the first step. This allows the nurse to gather more information and understand the client’s experience, which is essential for appropriate intervention.
Choice C rationale
Monitoring the client’s nonverbal behavior is important but should follow the initial assessment. Understanding the cause of the grimacing takes priority.
Choice D rationale
Reviewing the pain medications prescribed is a necessary step but should come after assessing the client’s current pain status and understanding the cause of the grimacing.