The nurse enters the room of a client who has fallen out of bed and is on the floor. The provider is notified and it is determined that the client was not injured. What is the best way to document this incidence in the nursing progress notes?
"Client found on floor despite repeated reminders to use call light. No injuries noted. Soft wrist restraints applied per provider orders."
"Client discovered lying on floor in room. Provider called to bedside. No injuries noted. Client returned to bed with bed alarm on, call light in reach."
"Client fell out of bed. Provider notified. No apparent injuries. Client reminded to use call light. Side rails up x 4."
"Client discovered out of bed on the floor after side rails left down. Client not injured. See incident report."
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The Correct Answer is B
A. "Client found on floor despite repeated reminders to use call light. No injuries noted. Soft wrist restraints applied per provider orders.": Documenting the use of restraints without clear justification or physician orders specific to fall prevention may imply inappropriate use, and this wording also introduces judgment about the patient’s behavior (“despite repeated reminders”), which is not objective or professional documentation.
B. "Client discovered lying on floor in room. Provider called to bedside. No injuries noted. Client returned to bed with bed alarm on, call light in reach.": This entry objectively describes the event, the immediate clinical response, and the interventions implemented to prevent recurrence. It avoids judgmental language and focuses on factual, patient-centered actions, aligning with professional standards for incident documentation in nursing notes.
C. "Client fell out of bed. Provider notified. No apparent injuries. Client reminded to use call light. Side rails up x 4.": While factual, this documentation includes assumptions (“fell out of bed”) and focuses more on restraint or safety devices rather than emphasizing objective observation and immediate care. “No apparent injuries” is slightly less precise than “no injuries noted” in clinical reporting.
D. "Client discovered out of bed on the floor after side rails left down. Client not injured. See incident report.": Including blame or speculative cause (“after side rails left down”) is inappropriate for nursing progress notes, which should remain objective and free from judgment. Referring to an incident report without documenting the nursing assessment and immediate interventions provides incomplete information for continuity of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hyperphosphatemia: Elevated phosphate levels are commonly associated with renal failure and can lead to hypocalcemia due to calcium-phosphate binding. Clinical manifestations often include muscle cramps, tetany, and sometimes soft tissue calcifications. Intense thirst, dry mucous membranes, and dehydration are not characteristic of hyperphosphatemia.
B. Hyperkalemia: Hyperkalemia primarily affects cardiac and neuromuscular function, presenting with symptoms such as muscle weakness, paresthesia, and potentially life-threatening dysrhythmias. Gastrointestinal symptoms may include diarrhea rather than nausea and vomiting, and it does not typically cause pronounced thirst or dry mucosa.
C. Hypocalcemia: Hypocalcemia is associated with neuromuscular excitability, including tetany, muscle spasms, seizures, and positive Chvostek’s or Trousseau’s signs. It does not present with dehydration-related symptoms such as extreme thirst or dry oral mucosa.
D. Hypernatremia: Hypernatremia reflects a relative water deficit leading to increased serum sodium concentration. It commonly presents with intense thirst, dry mucous membranes, restlessness, and neurologic changes due to cellular dehydration, especially in the brain. Nausea and vomiting may also occur, and the symptoms reflects dehydration and hyperosmolarity.
Correct Answer is A
Explanation
A. Prolongs expiration to reduce airway resistance: Pursed-lip breathing is a technique that slows exhalation, creating back pressure in the airways. This helps prevent airway collapse, particularly in patients with obstructive pulmonary conditions such as COPD, improves alveolar ventilation, enhances gas exchange, and reduces dyspnea. Prolonged expiration also helps decrease air trapping and promotes more effective ventilation.
B. Reduces the need for PRN pain medications: Pursed-lip breathing is not intended to control pain. While relaxation and improved oxygenation may reduce anxiety or discomfort related to dyspnea, it does not have a direct analgesic effect or replace prescribed pain management strategies.
C. Uses upper chest muscles more effectively: The technique primarily focuses on controlled diaphragmatic and lip-controlled exhalation rather than emphasizing upper chest muscle activity. Overusing upper chest muscles can increase fatigue and is not the goal of this breathing technique.
D. Replaces the use of incentive spirometry: Pursed-lip breathing does not serve the same purpose as incentive spirometry, which promotes deep inhalation to prevent atelectasis. While both improve pulmonary function, pursed-lip breathing specifically targets exhalation and airway patency, not inspiratory lung expansion.
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