A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

"Incident report completed."

"Client climbed over the side rails."

"Client found lying on floor."

"Client was trying to get out of bed."

Answer and Explanation

The Correct Answer is C

A. "Incident report completed.": Documentation should focus on objective observations rather than the completion of internal reporting. Noting that an incident report was filed is administrative and does not provide factual information about what actually occurred to the client.

B. "Client climbed over the side rails.": This statement implies judgment and assigns cause without objective verification. Documentation should remain factual and neutral, avoiding assumptions about the client’s intent or actions unless directly observed.

C. "Client found lying on floor.": Objective, factual statements describing what the nurse observed are the cornerstone of accurate documentation. This statement clearly records the client’s position and condition without adding interpretation or blame, providing a reliable record for medical and legal purposes.

D. "Client was trying to get out of bed.": While this information comes from the roommate, it is subjective and represents secondhand information. Documentation should distinguish between what was observed by the nurse versus what was reported by others, to avoid assumptions in the medical record.

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Correct Answer is C

Explanation

A. Verify the client's name on their identification bracelet with the medication administration record: While confirming the client’s identity is a critical safety step before administering medications, this action is part of the “five rights” of medication administration rather than the medication reconciliation process.

B. Call the pharmacy to determine whether the client's medications are available: Contacting the pharmacy may be necessary for obtaining or refilling prescriptions, but it is not part of the reconciliation process. Medication reconciliation focuses on comparing existing medications with new orders to prevent omissions, duplications, or interactions.

C. Compare the client's home medications with the provider's prescriptions: This is the primary purpose of medication reconciliation. The nurse reviews the client’s current medications, including prescription, over-the-counter, and herbal supplements, and compares them with new provider orders to identify discrepancies, prevent medication errors, and ensure continuity of care.

D. Place the client's home medication bottles in a secure location: Safely storing the client’s home medications is important for preventing misuse or errors, but it is a supportive action rather than part of the reconciliation process. The critical step is analyzing and reconciling the medications to ensure safe and accurate therapy.

A. The tube aspirate has a pH of 7 (less than 5). B. An x-ray shows the end of the tube above the pylorus. C. Bowel sounds are present on auscultation. D. The client reports relief of nausea.

Correct Answer is B

Explanation

A. The tube aspirate has a pH of 7 (less than 5): Gastric aspirate typically has an acidic pH ranging from about 1 to 5 due to the presence of hydrochloric acid in the stomach. A pH of 7 is neutral and more consistent with respiratory or intestinal secretions rather than gastric contents. Therefore, this finding does not reliably confirm that the NG tube is correctly positioned in the stomach.

B. An x-ray shows the end of the tube above the pylorus: Radiographic confirmation is considered the gold standard for verifying nasogastric tube placement. An x-ray showing the tube tip located within the stomach, above the pylorus, confirms that the tube has not entered the respiratory tract and is positioned appropriately for gastric decompression or feeding. This method provides the most accurate and reliable confirmation of placement.

C. Bowel sounds are present on auscultation: The presence of bowel sounds only indicates intestinal motility and does not provide information about the position of the NG tube. Historically, auscultating for air insufflation (“whooshing” sound) was used to check placement, but this practice is unreliable because similar sounds can occur even when the tube is misplaced in the lungs.

D. The client reports relief of nausea: Symptom relief may occur after gastric decompression but does not confirm correct placement of the tube. A client might experience temporary relief even if the tube is partially misplaced. Objective verification methods such as radiographic confirmation are necessary to ensure safe and correct tube positioning.

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A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

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Correct Answer is C

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Correct Answer is B

Explanation

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