A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?

Choice A reason: Blaming assistive personnel is subjective and speculative, not factual documentation. Falls may have multiple causes—mobility or environment—not just slippers. Legally and scientifically, records require objective data, not assumptions, to ensure accurate care planning and avoid liability missteps in clinical reporting.

Choice B reason: Quoting the client’s account provides objective, firsthand data about the fall’s circumstances—loss of balance during transfer. This factual detail aids in assessing risk factors like mobility or weakness, aligning with scientific documentation standards for precision and relevance in medical records.

Choice C reason: Incident reports are separate from medical records; mentioning one here is inappropriate. It’s an administrative action, not clinical data, and risks redundancy. Scientifically, records focus on patient status, not process notes, ensuring clarity for care continuity over procedural documentation.

Choice D reason: "Does not appear" is vague, not definitive, lacking objective findings like "no bruising noted." Documentation requires specific observations for accuracy. Scientifically, imprecise language weakens care planning, as it fails to confirm injury status with measurable evidence needed for clinical decisions.

Choice A reason: Injecting 15 units of air into regular insulin balances vial pressure, per protocol. This step precedes drawing regular insulin, ensuring accurate mixing sequence.

Choice B reason: Withdrawing NPH now skips regular insulin prep, risking contamination or error. Air injection into both vials comes first in standard insulin administration.

Choice C reason: Verification is key but follows insulin preparation. Air injection sequence precedes dosage checks, making this premature before completing vial prep steps.

Choice D reason: Capping the needle halts the process prematurely. Air must be injected into both vials first to maintain sterile technique and accurate dosing.