At 0915 the Nurse Repeatedly Instructs the Patient to Remain

At 0915 the nurse repeatedly instructs the patient to remain in bed.At 0930 the nurse enters the patient's room, finds the patient on the floor, and hears the patient say, "I need pain medicine." Which should the nurse do to document this event?

A) Label the late entry using the time of 9:15 AM.
B) Enclose the patient statement within quotations.
C) Document completion of an incident report.
D) Record plan to administer pain medication.