The nurse hears the patient calling for help and enters the room to find the patient on the floor. One of the side rails is down on the bed. Which documentation is most appropriate?

The side rail of the bed was down, and the patient was found on the floor. Proper reporting of incidents is to document what was observed factually and accurately. As the nurse did not witness the fall or the preceding events, the nurse can only speak to what was observed: the side rail was down and the patient was on the floor. It is not accurate to say the client fell out of bed or the client lowered the side rail themselves because the nurse did not witness these events. It is also not appropriate to suggest the side rail was not secured by hospital staff as this is not known fact.

The nurse hears the patient calling for help and enters the room ...

Category: Safety and Infection Control
Difficulty: 5

Topics: Communication & Documentation Assessment Health Care Ethics, Law, and Policy Health Care Quality Mobility

Want help? View the answer with rationale.

Additional Safety and Infection Control Questions

The patient with a long history of intravenous drug abuse presents to the emergency department with white lesions on both sides of the tongue that change appearance every couple of days. Despite fatigue and recent weight loss, the patient’s assessment is normal. Which type of precautions does the nurse use for this patient?

Question Type: Multiple Choice - Select One
Difficulty: 5

After reviewing the patient’s chart, which order(s) require clarification? Review the patient’s chart, then select all that apply.

Question Type: Multiple Choice - Select All
Difficulty: 10

The nurse is creating fire safety flyers for the hospital. What does the E in RACE signify?

Question Type: Multiple Choice - Select One
Difficulty: 1

Show Calculator

Want help? View the answer with rationale.

Rationale

Additional Safety and Infection Control Questions

Nursing Careers

Nursing Degrees

NCLEX