The Patient Was in Bed with All Side Rails Up

question 22

Multiple Choice

The patient was in bed with all side rails up.During the night,the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails.After meeting the patient's needs and assessing that the patient was not harmed,what step should the nurse take (if any) ?

• A)Complete an incident report and put it in the medical record.
• B)Chart what happened and state that an incident report has been filled out.
• C)Do nothing because the patient was not harmed.
• D)Document what happened in the patient record without mentioning the incident report.

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