A Nurse Forgets to Raise the Bed Railings of a Client

Multiple Choice

A nurse forgets to raise the bed railings of a client who is confused after taking pain medications. The client attempts to get out of bed, and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the client only had minor bruises. What would be the appropriate action of the colleague?

A) No other steps need to be taken, since the client was not seriously injured.
B) The colleague should inform the nurse that a full report of the incident needs to be made.
C) The colleague should monitor the client closely for any adverse effects of the fall.
D) The colleague should report the incident in a peer review of the nurse.