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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

D. Inserting an indwelling catheter involves placing a tube into the bladder through the urethra. The urethra and urinary tract are sterile areas. Sterile gloves are necessary to prevent introducing pathogens into the urinary tract during catheter insertion.

A. An enema involves introducing a solution into the rectum for therapeutic purposes. It does not require the use of sterile gloves because the rectum and lower gastrointestinal tract are not considered sterile areas.

B. Administering an intramuscular injection involves injecting medication into muscle tissue. It does not require sterile gloves unless the site needs to be cleaned with an antiseptic wipe, in which case non- sterile gloves are sufficient.

C. The insertion of a nasogastric tube also does not typically require sterile gloves, as the gastrointestinal tract is not a sterile environment.

A. document the error. B. call the physician. C. notify the supervisor. D. assess the client.

Correct Answer is D

Explanation

D. Assessing the client is the nurse's first responsibility when a medication error is suspected. The nurse should promptly assess the client's condition to determine if any harm has occurred as a result of the error. This assessment includes vital signs, physical assessment, and evaluation of any signs or symptoms related to the medication error.

A. Documenting the medication error is important for accurate record-keeping and subsequent investigation. However, it should not be the nurse's first action. The priority should be to assess and address any potential harm to the client.

B. Calling the physician may be necessary depending on the severity of the error and the client's condition. However, it is not the first responsibility of the nurse in response to a suspected medication error. The nurse's primary concern should be the immediate assessment and management of the client's condition.

C. Notifying the supervisor or charge nurse is an important step to report the incident and seek guidance on next steps. Supervisors can assist in managing the situation, implementing corrective measures, and ensuring appropriate documentation and reporting procedures are followed. This is typically one of the first actions after ensuring the client's safety.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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