After ambulating a client to the bathroom, the unlicensed ...

[gonzo233]

After ambulating a client to the bathroom, the unlicensed assistive personnel did not reattach the client's bed safety-monitoring device, and the client fell out of bed. What should the nurse document?
 
  1. Client fell out of bed; bed safety-monitoring device malfunctioning..
  2. Client fell out of bed; client removed leg band of bed safety monitoring device.
  3. Client fell out of bed; no observable injuries.
  4. Client fell out of bed; bed safety-monitoring device not activated.

Question 2

A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this client's documentation?
 
  1. Who assisted the client back to bed.
  2. Location of the seizure.
  3. Duration of the seizure.
  4. Status of airway and use of oxygen.
  5. Who discovered the client.

[mcinincha279]

Answer to Question 1

Correct Answer: 4
Rationale 1: The bed safety device was not activated. It was not malfunctioning.
Rationale 2: The client did not remove the leg band of the monitoring device.
Rationale 3: The nurse needs to report the fall to the primary care physician.
Rationale 4: The nurse needs to document what occurred with the client and why.

Answer to Question 2

Correct Answer: 2,3,4
Rationale 1: It is not important for the nurse to name the individuals who assisted the client back to bed.
Rationale 2: Documentation should include where the client was when the seizure occurred.
Rationale 3: Documentation should include the duration of the seizure.
Rationale 4: Documentation should include the status of the client's airway and use of oxygen.
Rationale 5: It is not important for the nurse to name the individual who found the client having a seizure.

[gonzo233]

Thank you!

[mcinincha279]

Always glad to help...