The nurse is caring for a client with a fluid volume deficit and hypovolemia. What actions can the nurse take without a physician's order?

A. Trash can accidentally left in path to bathroom: This option accurately documents the environmental factor that contributed to the client's fall. It provides relevant information about the incident, highlighting the presence of a hazard (the trash can) in the path to the bathroom, which led to the fall. Documenting such environmental factors is essential for identifying safety issues and implementing preventive measures.

B. States, "I think I only bruised my left knee": While documenting the client's statement about the extent of their injury is important for assessing and addressing their physical condition, it does not directly address the environmental factor that contributed to the fall. This information may be included in the assessment section of the chart but may not fully capture the circumstances surrounding the fall.

C. Noncompliant with use of call bell: This statement implies a judgment about the client's behavior rather than documenting the circumstances of the fall. While noncompliance with safety measures such as using the call bell may contribute to falls, it is important to focus on objective observations and environmental factors that directly contributed to the incident.

D. Seems angry and upset: Documenting the client's emotional state is relevant for understanding their response to the fall and providing appropriate psychosocial support. However, it does not directly address the cause of the fall or provide information about the environmental factor (the trash can) that contributed to the incident.

A. Sorry: Expressing regret or remorse for an error is important, but it does not fully encompass the ethical responsibility demonstrated in this scenario. While acknowledging the mistake and feeling sorry is essential, the nurse's primary ethical obligation lies in taking appropriate action to rectify the error and prevent harm to the client.

B. Accountable: Being accountable involves taking responsibility for one's actions, including acknowledging errors, reporting them promptly, and taking corrective measures. In this scenario, the nurse demonstrates accountability by recognizing the administration of a wrong dose of medication and promptly informing the supervisor. Accountability is a fundamental ethical principle in healthcare that promotes transparency, integrity, and patient safety.

C. Altruistic: Altruism involves acting in the best interests of others, often selflessly and without expecting personal gain. While reporting errors and ensuring patient safety can be considered altruistic actions, the primary ethical behavior demonstrated in this scenario is accountability, as the nurse takes responsibility for the medication error.

D. Just: Justice in healthcare refers to fairness, equity, and adherence to ethical principles in the distribution of resources and provision of care. While ensuring justice is an important ethical consideration in healthcare, it is not directly applicable to the nurse's behavior in this scenario. The primary ethical principle demonstrated here is accountability, as the nurse takes responsibility for the medication error and acts to address it appropriately.