When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding?
1. Client fell out of bed, but did push the call button for assistance.
2. Client became tangled in the bed linens, then called for assistance after falling out of bed.
3. Recorder responded to client's call light, upon entering the room, found client on floor.
4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.
Correct Answer: 3
Rationale 1: It should never be assumed that the client fell out of bed.
Rationale 2: It should never be assumed that the client fell out of bed, became tangled in bedding, or anything else.
Rationale 3: Accurate notations consist of facts or observations rather than opinions or interpretations. The client was found on the floor, and the call light was activated. Those are the only things known until the nurse learns further information from questioning the client.
Rationale 4: It should never be assumed that the client became tangled in bedding, or anything else.
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