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","E"]
Explanation
Choice A rationale
Asking the healthcare provider for a mild sedative for bedtime may not be the best first-line approach for improving sleep. Sedatives can have side effects and may lead to dependency. Non-pharmacological interventions are generally preferred for managing sleep disturbances in older adults.
Choice B rationale
Taking an afternoon nap to make up for missed sleep can disrupt the sleep-wake cycle and make it harder to fall asleep at night. It is generally recommended to avoid napping during the day to improve nighttime sleep quality.
Choice C rationale
Drinking a mixture of warm water, whiskey, and honey at bedtime is not a recommended practice for improving sleep. Alcohol can disrupt sleep patterns and lead to poor sleep quality. It is better to avoid alcohol before bedtime.
Choice D rationale
Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and improve sleep quality. Consistency in sleep schedules is a key factor in promoting healthy sleep habits.
Choice E rationale
Avoiding caffeinated beverages late in the day is important for improving sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep.
Correct Answer is C
Explanation
Choice A rationale
Removing dentures or other oral appliances is not the most critical intervention for a client with severe obstructive sleep apnea (OSA) who has received an opioid analgesic. The priority is to ensure airway patency.
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention because it directly maintains airway patency and prevents respiratory compromise, which is crucial for a client with severe OSA2.
Choice D rationale
Putting and locking the side rails in place is important for safety but does not address the critical need to maintain airway patency in a client with severe OSA.