A nurse assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?

A) "The client fell because the assistive personnel did not place nonskid slippers on the client.": This statement assigns blame to a specific individual (assistive personnel) for the fall, which is not appropriate for documentation. The nurse should focus on factual, objective information rather than assigning blame. Statements that imply fault without proper evidence or investigation should be avoided in medical records.

B) *Client stated, "I lost my balance and fell when I got out of bed to go to the bathroom.'": This statement accurately reflects the client’s account of the incident, which is a critical part of the documentation. The nurse should include the client’s own words when describing the event, as it provides essential context and ensures that the record is clear and unbiased. This statement is objective and factual.

C) "The client does not appear to have any injuries resulting from the fall.": While it’s important to assess for injuries, this statement could be too vague. The nurse should document a detailed assessment of the client’s physical condition post-fall, including any injuries, signs, or symptoms of injury. It is important to be thorough and specific in documenting the client's condition after the fall.

D) "An incident report has been completed and sent to risk management.": This information should not be included in the medical record. Incident reports are separate documents that are used for internal review and safety improvement purposes. Including this information in the medical record could lead to confusion and may not be relevant to the clinical care of the client.

A) Document the infiltration: While documentation is an important part of the nursing process, it is not the first action to take. If an infiltration is suspected, the priority is to stop the infusion immediately to prevent further harm or fluid leakage into the surrounding tissues. Once the infusion is stopped, the nurse can then document the infiltration for medical record purposes.

B) Elevate the arm: Elevating the arm can help reduce swelling, but this should not be the first step. The first priority when infiltration is suspected is to stop the infusion, as continuing it can worsen the tissue damage and swelling. After stopping the infusion, elevating the arm may be considered as part of the subsequent management of the infiltration.

C) Apply a warm compress: A warm compress may be helpful after stopping the infusion, particularly if the infiltration involves non-vesicant fluids. However, applying a warm compress is not the immediate action. The first step should be stopping the infusion to prevent any further fluid from infiltrating the tissues.

D) Stop the infusion: The most immediate and appropriate action when infiltration is noted around the IV insertion site is to stop the infusion. This prevents additional fluid from leaking into the surrounding tissues, which could cause further damage. Once the infusion is stopped, the nurse can take other steps to manage the infiltration, such as assessing the site, applying a warm compress, or notifying the healthcare provider.