{"id":141784,"date":"2024-09-21T07:53:16","date_gmt":"2024-09-21T07:53:16","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=141784"},"modified":"2024-09-21T07:53:19","modified_gmt":"2024-09-21T07:53:19","slug":"a-healthcare-organization-requires-nurses-to-chart-by-exception","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2024\/09\/21\/a-healthcare-organization-requires-nurses-to-chart-by-exception\/","title":{"rendered":"A healthcare organization requires nurses to chart by exception"},"content":{"rendered":"\n<p>A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?<\/p>\n\n\n\n<p>A.<br>Basilar lung sounds that are diminished in the left lung.<\/p>\n\n\n\n<p>B.<br>Contraction of the left pupil when light shines in the right eye.<\/p>\n\n\n\n<p>C.<br>Capillary refill of 2 seconds in the lower right foot.<\/p>\n\n\n\n<p>D.<br>Active bowel sounds in the lower right quadrant.<\/p>\n\n\n\n<p><mark style=\"background-color:rgba(0, 0, 0, 0)\" class=\"has-inline-color has-ast-global-color-6-color\"><strong>The correct answer and Explanation is :<\/strong><\/mark><\/p>\n\n\n\n<p>The correct answer is <strong>A. Basilar lung sounds that are diminished in the left lung.<\/strong><\/p>\n\n\n\n<p><strong>Explanation:<\/strong><\/p>\n\n\n\n<p>Charting by exception (CBE) is a documentation method used in healthcare where only deviations from the norm or significant findings are recorded, while routine or expected information is generally assumed to be normal and does not need to be documented. This approach helps streamline the documentation process, allowing healthcare providers to focus on significant changes in a patient&#8217;s condition that may require attention.<\/p>\n\n\n\n<p>In this context, option A, &#8220;Basilar lung sounds that are diminished in the left lung,&#8221; represents an abnormal finding. Diminished lung sounds can indicate a range of issues, such as atelectasis, pleural effusion, or pneumonia, and require further assessment or intervention. Therefore, this assessment must be documented because it deviates from normal expectations and may impact the patient&#8217;s care plan.<\/p>\n\n\n\n<p>In contrast, the other options describe normal or expected findings that do not necessitate documentation under the CBE framework:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>B. Contraction of the left pupil when light shines in the right eye<\/strong> describes a normal physiological response called consensual reflex and would not typically be documented unless abnormal.<\/li>\n\n\n\n<li><strong>C. Capillary refill of 2 seconds in the lower right foot<\/strong> is also a normal finding; capillary refill of less than 2 seconds is expected in healthy individuals.<\/li>\n\n\n\n<li><strong>D. Active bowel sounds in the lower right quadrant<\/strong> is considered a normal finding as well, indicating that the gastrointestinal system is functioning properly.<\/li>\n<\/ul>\n\n\n\n<p>In summary, under the charting by exception methodology, abnormal findings such as diminished lung sounds (option A) should be documented to ensure continuity of care and appropriate follow-up, while normal findings can be assumed to be within expected parameters and do not need to be recorded.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document? A.Basilar lung sounds that are diminished in the left lung. B.Contraction of the left pupil when light shines in the right eye. C.Capillary refill of 2 seconds in the lower right foot. D.Active bowel sounds in the lower right quadrant. 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