NCLEX RN Practice Questions # 13

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?

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.

Rationale