When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding?

Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.

Client fell out of bed, but did push the call button for assistance.

Recorder responded to client's call light, upon entering the room, found client on floor

Client became tangled in the bed linens, then called for assistance after falling out of bed.

Answer and Explanation

The Correct Answer is C

C. This entry is factual and avoids assumptions about how the client ended up on the floor, focusing instead on the sequence of events as discovered by the recorder. It is important to avoid speculation and to document only what is directly observed or verifiable.

A. This option provides a clear description of the situation: the client was found on the floor, and it attributes the fall to getting tangled in bed linens. However, it includes an assumption of how the client fell.

B. This option indicates that the client fell out of bed and did push the call button for assistance. While it acknowledges the fall and the use of the call button, it doesn't specify who found the client on the floor or the circumstances surrounding the discovery.

D. This option suggests that the client called for assistance after falling out of bed due to being tangled in bed linens. It mentions the sequence of events (tangled in bed linens first, then called for assistance), but it doesn't specify who found the client on the floor or the action taken thereafter.

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Correct Answer is C

Explanation

C. Range-of-motion (ROM) exercises are essential in preventing contractures. These exercises aim to maintain or improve joint mobility by moving each joint through its full range of movement. They help stretch tight muscles and maintain flexibility, thereby preventing the progression of contractures.

A. While muscle strengthening exercises are beneficial for overall muscle health, in the context of contractures, the primary issue is the shortened and tight muscles. Strengthening exercises alone may not effectively address the contractures and could potentially exacerbate them.

B. Frequent repositioning is crucial to prevent and potentially reverse contractures. By changing the client's position regularly, pressure and stress on specific muscle groups are relieved, which can help prevent further tightening and promote flexibility. This intervention helps maintain joint mobility and prevents contractures from worsening.

D. Weight-bearing activities can be beneficial for joint health and bone density but may not directly address contractures. Contractures involve structural changes in the muscle-tendon unit rather than joint stiffness alone.

A. Drugs given subcutaneously are absorbed more quickly than those given intramuscularly. B. Most drugs must enter the systemic circulation to have a therapeutic effect. C. Most oral medications are absorbed more quickly when administered with meals. D. Mucous membranes are relatively impermeable to chemicals, making absorption slow.

Correct Answer is B

Explanation

B. Drug absorption refers to the process by which a drug moves from its site of administration into the bloodstream. Once absorbed into the bloodstream (systemic circulation), drugs can distribute to various tissues and exert their therapeutic effects.

A. Different routes of drug administration affect the rate and extent of absorption. Subcutaneous injections are generally absorbed more quickly than intramuscular injections due to differences in blood flow and tissue characteristics.

C. The effect of meals on drug absorption varies depending on the specific medication. Some drugs are absorbed faster on an empty stomach, while others may be absorbed better with food.

D. Mucous membranes, contrary to the statement, are relatively permeable to drugs, allowing for rapid absorption when medications are administered via buccal, sublingual, rectal, or vaginal routes.

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When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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