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A nurse hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying on the floor. The nurse performs a thorough assessment, assists the client back to bed, notifies the physician of the incident, and completes an incident report. Which of the following should the nurse document on the incident report?
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1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to get out of bed.
Answer and Rationale:
Option 3 is Correct answer.
Rationale: The incident report should contain the client’s name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. Option 3 is the only option that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.
Test-Taking Strategy: Use the process of elimination and read the information contained in the question to select the correct option. Remember to focus on factual information when documenting, and avoid including interpretations. This will direct you to option 3. Review documentation principles related to incident reports if you had difficulty with this question.
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