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.
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.
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