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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["A","C","E","G"]
Explanation
Choice A rationale
Measuring vital signs at 0800 is a standard practice in many healthcare settings to establish a baseline for the day.
Choice B rationale
Measuring vital signs at 1000 is not typically a standard time unless there is a specific clinical indication.
Choice C rationale
Measuring vital signs at 1200 helps monitor the client’s status around midday and can be important for assessing the effects of morning medications or treatments.
Choice D rationale
Measuring vital signs at 1400 is not typically a standard time unless there is a specific clinical indication.
Choice E rationale
Measuring vital signs at 1600 helps monitor the client’s status in the afternoon and can be important for assessing the effects of afternoon medications or treatments.
Choice F rationale
Measuring vital signs at 1800 is not typically a standard time unless there is a specific clinical indication.
Choice G rationale
Measuring vital signs at 2000 helps monitor the client’s status in the evening and can be important for assessing the effects of evening medications or treatments.
Correct Answer is A
Explanation
Choice A rationale
Beginning with queries that are less sensitive in nature can help establish rapport and trust with the client. This approach makes the client more comfortable and willing to disclose personal information, including details about sexual activity.
Choice B rationale
Asking queries in a vague, non-specific format may lead to confusion and incomplete information. It is important to ask clear and direct questions to obtain accurate information.
Choice C rationale
Getting the most difficult queries over with first may cause the client to feel uncomfortable and defensive, making it harder to obtain accurate information.
Choice D rationale
Sharing personal values to put the client at ease is not appropriate in a professional setting. The nurse should maintain a neutral and non-judgmental approach to encourage open communication.