A nurse is caring for a client who received a sedative medication at bedtime and becomes confused during the night. The client falls while getting out of bed, sustaining a laceration to the head that requires suturing. Which of the following notations should the nurse make when documenting in the client's medical record?

"Client fell out of bed and cut his forehead due to sedative-induced confusion."

"Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."

"Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."

"Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in medical record for further details."

Answer and Explanation

The Correct Answer is C

A. "Client fell out of bed and cut his forehead due to sedative-induced confusion."

This option provides information about the fall and the cause but lacks specific details about the injury, location, or the client's orientation. It is not as detailed or objective as it could be.

B. "Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."

This option includes information about the client's position, the presence of blood, and attributes the fall to the failure of the assistive personnel to put up side rails. While it provides some details, it introduces an element of blame and speculation. It's important to stick to factual information in documentation.

C. "Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."

This option provides specific details about the client's position, the nature and location of the injury (laceration), and the client's orientation status. It is concise, objective, and focused on the relevant information.

D. "Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in the medical record for further details."

This option includes information about the fall, the injury, and refers to an incident report for further details. While it provides information, it may be more appropriate to include essential details directly in the documentation rather than referring to another document for additional information.

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Correct Answer is D

Explanation

A. Keeping the lights on when the client is sleeping is not a standard intervention for seizure precautions. In fact, it's generally recommended to create a quiet and low-stimulus environment for clients with seizure disorders.

B. Restraining the client as soon as seizure activity begins is not recommended. Restraints can lead to injuries and complications during a seizure. It is essential to allow the client to move and prevent injury by removing harmful objects from the vicinity.

C. Having a padded tongue depressor available at the bedside is not a standard intervention for seizure precautions. In the event of a seizure, the priority is to keep the client safe, protect their head, and ensure a clear airway. Placing objects in the mouth is not recommended and can lead to injury.

D. Keeping the client's bed in the lowest position is a safety measure to prevent injuries during a seizure. It reduces the risk of falling from a significant height in case of a seizure episode.

A. Move any clients in the immediate vicinity. B. Close the fire doors on the unit. C. Use a fire extinguisher on the outlet. D. Activate the fire alarm.

Correct Answer is D

Explanation

A. Move any clients in the immediate vicinity.

This is a reasonable next step, ensuring the safety of clients in close proximity to the potentially hazardous situation.

B. Close the fire doors on the unit.

Closing fire doors is important for containing the spread of smoke and fire, but it may be a secondary action after alerting others to the emergency using the fire alarm.

C. Use a fire extinguisher on the outlet.

While fire extinguishers can be useful in certain situations, using one on an electrical fire can be dangerous. It's generally recommended to leave firefighting to trained personnel and focus on evacuation and alerting others.

D. Activate the fire alarm.

Activating the fire alarm is the priority because it alerts everyone in the facility to the potential danger, ensuring a prompt and coordinated response. It initiates the facility's fire response plan and helps in the evacuation of patients if necessary.

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Naxlex Comprehensive Predictor Exams

A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?

Correct Answer is D

Explanation

A nurse is caring for a client when the safety on the bed plug's electrical outlet pops and begins to smoke. Which of the following actions is the nurse's priority?

Correct Answer is D

Explanation

As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?

A nurse is reviewing a client's medication administration record. For which of the following medications should the nurse place the client on fall precautions?

A nurse is caring for a client who is experiencing menopausal symptoms and requests information about hormone replacement therapy (HRT). Which of the following items in the client's health history is a contraindication for hormone replacement therapy?

A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many ml. should the nurse administer? (Round to the nearest whole number.)

A nurse is caring for a client following major spinal surgery who is reporting pain. The client's partner tells the nurse, "I wish I could do something to make my wife feel better." Which of the following responses should the nurse make?

A float nurse is given a client assignment that requires the use of unfamiliar skills and techniques. Which of the following actions should the nurse take?

A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A nurse is preparing to administer valproic acid 500 mg PO. Available is valproic acid oral solution 250 mg/5 mL. How many ml should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)