When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding?
Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.
Client fell out of bed, but did push the call button for assistance.
Recorder responded to client's call light, upon entering the room, found client on floor
Client became tangled in the bed linens, then called for assistance after falling out of bed.
The Correct Answer is C
C. This entry is factual and avoids assumptions about how the client ended up on the floor, focusing instead on the sequence of events as discovered by the recorder. It is important to avoid speculation and to document only what is directly observed or verifiable.
A. This option provides a clear description of the situation: the client was found on the floor, and it attributes the fall to getting tangled in bed linens. However, it includes an assumption of how the client fell.
B. This option indicates that the client fell out of bed and did push the call button for assistance. While it acknowledges the fall and the use of the call button, it doesn't specify who found the client on the floor or the circumstances surrounding the discovery.
D. This option suggests that the client called for assistance after falling out of bed due to being tangled in bed linens. It mentions the sequence of events (tangled in bed linens first, then called for assistance), but it doesn't specify who found the client on the floor or the action taken thereafter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. These effects are not the primary intended outcomes of the medication, but are known possible reactions that can occur in addition to the main therapeutic effect.
A. Synergistic effects refer to the combined action of two or more substances or medications that results in an effect greater than the sum of their individual effects.
B. Adverse effects are unintended and potentially harmful effects of a medication, even when the medication is used at therapeutic doses and in the correct manner.
C. Therapeutic effects are the desired and beneficial effects of a medication that contribute to treating or managing a medical condition. These effects are intended and typically guide the prescribing and administration of medications.
Correct Answer is C
Explanation
C. This is the priority intervention because clients in protective isolation have compromised immune systems and are at high risk of infection. Upper respiratory infections can be transmitted easily through respiratory droplets, posing a significant risk to the client. Restricting visitors with such infections helps minimize the risk of introducing pathogens into the client's environment.
A. While maintaining cleanliness is important in any healthcare setting, changing bed linens daily may not be the highest priority in protective environment isolation unless there is a specific indication (e.g., soiled linens, contamination). It is essential to minimize unnecessary contact and potential sources of infection, but this is not the priority in the given context.
B. Hydration is important for all clients, but the frequency of providing fresh drinking water every four hours is generally a routine nursing care measure. Unless there are specific medical orders or client needs, this action is not directly related to the specialized care required in protective environment isolation.
D. Monitoring intake and output is important for assessing fluid balance and kidney function in hospitalized clients. However, in the context of protective isolation, where infection control is paramount, restricting visitors who pose a potential infectious risk takes precedence over routine monitoring tasks.
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