A nurse is caring for a client who received a sedative medication at bedtime and becomes confused during the night. The client falls while getting out of bed, sustaining a laceration to the head that requires suturing. Which of the following notations should the nurse make when documenting in the client's medical record?

"Client fell out of bed and cut his forehead due to sedative-induced confusion."

"Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."

"Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."

"Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in medical record for further details."

Answer and Explanation

The Correct Answer is C

A. "Client fell out of bed and cut his forehead due to sedative-induced confusion."

This option provides information about the fall and the cause but lacks specific details about the injury, location, or the client's orientation. It is not as detailed or objective as it could be.

B. "Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."

This option includes information about the client's position, the presence of blood, and attributes the fall to the failure of the assistive personnel to put up side rails. While it provides some details, it introduces an element of blame and speculation. It's important to stick to factual information in documentation.

C. "Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."

This option provides specific details about the client's position, the nature and location of the injury (laceration), and the client's orientation status. It is concise, objective, and focused on the relevant information.

D. "Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in the medical record for further details."

This option includes information about the fall, the injury, and refers to an incident report for further details. While it provides information, it may be more appropriate to include essential details directly in the documentation rather than referring to another document for additional information.

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Correct Answer is A

Explanation

A. Discontinuing the existing IV infusion is the priority when signs of infection or inflammation are present at the site. This action helps prevent the spread of infection and allows for a thorough assessment of the site.

B. Inserting an IV catheter in the opposite extremity is not the first step. Before considering a new IV site, it's crucial to address the issue with the current site. Starting a new IV line before addressing the potential infection could lead to further complications.

C. Applying warm, moist compresses to the site is not the first action. While warm compresses can be used to promote blood flow and comfort, the priority is to discontinue the current infusion and assess for infection or inflammation.

D. Elevating the extremity is not the first action in response to signs of infection or inflammation at an IV site. The priority is to discontinue the infusion and assess the site for potential complications.

A. Provide client care as assigned. B. Make a formal complaint to the nursing manager. C. Request the charge nurse to modify the assignment. D. Ask another nurse to trade assignments.

Correct Answer is D

Explanation

A. Provide client care as assigned:

While it is essential to be flexible and adaptable, patient safety is a priority. If the nurse is not familiar with certain skills or techniques and believes it could compromise patient safety, blindly providing care may not be the best option.

B. Make a formal complaint to the nursing manager:

Making a formal complaint should not be the initial step. It is better to explore other options before escalating the situation to a higher level.

C. Request the charge nurse to modify the assignment:

This is a reasonable option. The nurse can communicate concerns to the charge nurse and request modifications to the assignment based on their skills and competency.

D. Ask another nurse to trade assignments:

This is the most immediate and practical solution. If there's another nurse available who is more familiar with the required skills, trading assignments can ensure that the patient receives appropriate care from a nurse with the necessary expertise.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?

Correct Answer is A

Explanation

A float nurse is given a client assignment that requires the use of unfamiliar skills and techniques. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing menopausal symptoms and requests information about hormone replacement therapy (HRT). Which of the following items in the client's health history is a contraindication for hormone replacement therapy?

A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

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