Practice Quiz

NCLEX-RN

Category - Safety

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A nurse hears a client calling out for help. As the nurse enters the client’s room, the client is found conscious and lying on the floor. The bed’s side rails are down. The nurse should document which of the following in the incident’s report?
  1. The client fell from the bed, but is conscious. The side rails were down.
  2. The client was found conscious and lying on the floor. The side rails were down.
  3. The client climbed out of the bed, forcing the side rails down.
  4. The client lost his or her balance and fell.
Explanation
Answer: B - The incident report would only include what is seen by the nurse and an accurate description of the incident. The incident also includes the client’s name, age, diagnosis, injuries sustained, and outcome of the situation.
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