A nurse has just finished a wound care procedure for a client. Which of the following should the nurse remove first?

A. Ask the assistive personnel to document the client's time of death: Documenting the time of death is a critical nursing responsibility and should be done by the nurse or healthcare provider, not delegated to assistive personnel. Accurate documentation is essential for legal and medical records, especially when an autopsy is planned.

B. Wear sterile gloves when cleaning the client's body: Sterile gloves are not necessary for routine postmortem care; clean gloves are sufficient. Sterile gloves are reserved for invasive procedures to prevent infection, whereas postmortem care focuses on hygiene and respect for the deceased.

C. Place an identification tag on the outside of the client's shroud: Proper identification of the deceased is crucial, especially when an autopsy is required. Placing an identification tag on the shroud ensures correct identification during transport and handling, preventing misidentification and maintaining respect for the client.

D. Remove the client's dentures and give them to the client's family: Dentures should typically remain in the client's mouth during postmortem care to preserve facial structure and appearance. Removing them can alter the deceased’s appearance, which may be distressing to the family and is generally avoided unless specifically requested.

A. Measure the intake and output of a client who has received furosemide: Measuring intake and output is within the scope of practice for assistive personnel. The nurse remains responsible for interpreting the data and notifying the provider of any concerns.

B. Check a client's peripheral IV site for redness or swelling: Assessment of IV sites for complications such as infiltration, phlebitis, or infection requires clinical judgment and should be performed by licensed nursing personnel.

C. Assess the pain level of a client who has received acetaminophen: Pain assessment requires clinical judgment, interpretation of client responses, and knowledge of pain scales. Only licensed nurses should perform pain assessments and determine the effectiveness of interventions.

D. Reinforce teaching with a client about crutch-gait walking: Reinforcing teaching involves understanding and communicating clinical concepts accurately. Even though it may seem routine, instructing or clarifying a gait technique requires nursing knowledge to ensure client safety and proper technique.