NCLEX · General

A nurse finds a client on the floor next to the bed. After ensuring the client's immediate safety and assessing for injury, what is the next priority action?

Correct answer

Notify the RN and provider, then document the objective findings in the medical record; the incident report is completed separately and is NOT referenced in the chart

  1. A Complete an incident report immediately
  2. B Notify the RN and provider, then document the objective findings in the medical record; the incident report is completed separately and is NOT referenced in the chart
  3. C Move the client back to bed quickly
  4. D Call the family first

Why this is the answer

POST-FALL PROTOCOL: SEQUENCE: (1) Ensure immediate safety; assess for injury (don't move if spinal injury suspected); assess level of consciousness, vital signs, pain, range of motion, any deformity; (2) Provide necessary care/stabilization; (3) Notify the RN and provider; (4) Document OBJECTIVE findings in the medical record (what you found, the client's condition, actions taken, who was notified) — factually, without speculation about cause or blame; (5) Complete an INCIDENT REPORT (occurrence/variance report) separately — this is an internal quality/risk management document; KEY POINT: The incident report is NOT part of the medical record and should NOT be referenced in the chart ('incident report completed' should NOT be charted) — they are kept separate for legal reasons; documentation should be factual and objective; FALL ASSESSMENT: Reassess fall risk; implement additional precautions; LPN role: ensure safety, assess, notify, document objectively, complete incident report per facility policy.
Source: NCLEX-PN Safe Care — Post-Fall Protocol and Documentation