A physical therapist (PT) places a gait belt on a ...

HESI RN MEDICAL SURGICAL EXAM PACK QUESTIONS AND ANSWERS

Question Number 11

A physical therapist (PT) places a gait belt on a client and is assisting them with ambulation from the bed to the chair. As they get up out of the bed, they report being dizzy and begin to fall. The PT carefully allows them to fall back to the bed and notifies the primary nurse. Which written documentation should the nurse put in the client's record? A) Client experienced orthostatic hypotension when getting out of bed.B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow client to fall back onto the bed.C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness.D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed.

B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow client to fall back onto the bed.Rationale: This documentation provides the factual data of the events that occurred. A)The nurse is making an assumption that the dizziness was caused by orthostatic hypotension. C) Not all the pertinent facts are included in this documentation.D) A variance report should never be documented in the client's record.

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HESI RN MEDICAL SURGICAL EXAM PACK QUESTIONS AND ANSWERS

Question Number 11

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