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. pump the cuff up again immediately before releasing it. B. use the client's radial pulse to determine how high to pump up the cuff C. obtain another cuff and take the blood pressure again in 30 minutes. D. release the cuff completely and wait two minutes before retaking the blood pressure.

Correct Answer is D

Explanation

D. When uncertain about the endpoint of Korotkoff sounds, releasing the cuff completely allows the blood flow to return to normal in the arm. After waiting for about two minutes, the nurse can reinflate the cuff and begin the measurement process again. This approach helps ensure accurate measurement by resetting conditions and allowing for a clearer determination of when Korotkoff sounds start and stop.

A. This option is not recommended because re-inflating the cuff immediately could lead to incorrect readings due to inaccurate pressure settings or discomfort for the client. It does not address the issue of determining the endpoint of the Korotkoff sounds.

B. This technique involves palpating the radial pulse while inflating the cuff and then inflating the cuff until the pulse is no longer palpable. This method can help ensure the cuff is inflated to an appropriate pressure level, which is typically about 30 mmHg above the point where the radial pulse disappears.

However, this option does not directly address the uncertainty about when to listen for the Korotkoff sounds to stop.

C. This option is not practical for addressing the immediate uncertainty during the current blood pressure measurement. Waiting 30 minutes to retake the blood pressure with a different cuff may delay necessary assessment and intervention.

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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

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