Practice Quiz

NCLEX-PN

Category - Safety

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During the night shift, the nurse caring for a 45-year-old client with encephalopathy forgot to raise the side rails of the client’s bed. While doing the usual rounds, the nurse sees the client sprawled on the floor. What is the initial action of the nurse?
  1. Assess the client
  2. Help the client return to the bed, keeping the side rails up
  3. Immediately return to the nurse’s station to ask for help
  4. Make an incident report
Explanation
Answer: A - The nurse should first assess the client for injury. Option B may come later if the client’s condition permits transfer to the bed. Option C is incorrect; the nurse should not leave the client unless necessary. The call light should be used for help, if needed. Incident reports are done later after the nurse establishes the stability of the client.
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