The nurse supervisor is working in a hospital that is in the path of a hurricane. Which of the following clients would be appropriate for immediate discharge?

Choice A reason: Reassessing the client when the provider arrives to obtain the informed consent may be necessary, but it is not the priority action. The nurse needs to ensure that the provider is aware of the client's current mental status before any attempt to obtain informed consent is made.

Choice B reason: Notifying the provider of the client's orientation is the priority action. The client's intermittent confusion indicates that she may not have the capacity to provide informed consent. The provider needs to be aware of this to take appropriate steps, such as involving a legal representative or family member, to obtain consent.

Choice C reason: Calling the nursing supervisor to give consent for the surgery is not appropriate. The nursing supervisor does not have the legal authority to provide consent on behalf of the client.

Choice D reason: Asking another nurse to witness the informed consent does not address the issue of the client's mental status and ability to provide informed consent. This action is not appropriate given the client's intermittent confusion.

Choice A reason: The statement "The client fell out of bed" is an assumption and not an objective observation. Documentation should include only factual information that is observed or measured, rather than conclusions or suppositions. Therefore, this statement should not be included in the incident report.

Choice B reason: Documenting the client's vital signs is crucial as it provides measurable data about the client's condition at the time of the incident. Recording blood pressure, pulse, and respirations helps to establish a baseline and can be used for future comparison to assess any changes in the client's status after the incident. This is a factual and objective piece of information that is appropriate for the incident report.

Choice C reason: Noting that no bruises or injuries were observed on the client is an important observation. This statement provides an objective assessment of the client's physical condition immediately after the fall, which is critical for ongoing monitoring and care. It helps to document that the client did not sustain visible injuries during the incident.

Choice D reason: The statement "The client apparently climbed over the side rails unwitnessed" includes speculation and is not based on direct observation. Documentation should avoid including subjective interpretations or assumptions about the events. Only witnessed and factual information should be recorded in the incident report to maintain accuracy and objectivity.

Choice E reason: Reporting that the health care provider was notified of the incident is essential for ensuring continuity of care. This statement documents the communication between the nurse and the provider, which is a critical step in the incident response process. It ensures that appropriate follow-up actions can be taken based on the provider's assessment and recommendations.