A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

Completion of an incident report.

Name of the nurse certifying the client's death.

Release of personal belongings form.

One client identifier at the client's time of death.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Release of personal belongings form.

Choice A rationale:

Completion of an incident report is not typically part of postmortem care documentation unless there was an unusual or unexpected event surrounding the death.

Choice B rationale:

While the name of the nurse certifying the client’s death is important, it is usually documented separately in the death certificate or other official records, not necessarily in the postmortem care documentation.

Choice C rationale:

The release of personal belongings form is crucial as it ensures that the client’s belongings are properly accounted for and handed over to the appropriate person, providing a clear record of what was released and to whom.

Choice D rationale:

Documenting one client identifier at the time of death is important, but it is not specific to postmortem care documentation. Identifiers are generally used throughout the client’s medical record to ensure accuracy and consistency.

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Correct Answer is D

Explanation

The correct answer is choice D. The client has tenderness and warmth in their calf.

Choice A rationale:

The client's self-reported incisional pain level of 7 on a scale of 0 to 10 is important information to assess postoperative recovery, but it is not the priority finding to report among the choices. Pain management is crucial, but potential complications that could be more urgent should be addressed first.

Choice B rationale:

Increased nausea and chills are concerning postoperative findings, but they could be related to the body's response to surgery, anesthesia, or pain medications. While these symptoms should be monitored and managed, they are not as high-priority as potential complications involving the calf.

Choice C rationale:

An oral temperature of 38.5°C (101.3°F) indicates a fever and is also a concerning finding in the postoperative period. Infection could be a possible cause, and the provider should be informed. However, compared to tenderness and warmth in the calf, which could suggest deep vein thrombosis (DVT), the fever is of slightly lower priority.

Choice D rationale:

Tenderness and warmth in the calf are the priority findings to report. These symptoms raise concern about the possibility of deep vein thrombosis (DVT), a serious complication after surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the legs. If left untreated, it can lead to a pulmonary embolism, a life-threatening condition where the clot travels to the lungs. Immediate assessment and intervention are necessary to rule out or address this potentially critical complication.

A. 1+ pitting edema. B. 2+ pitting edema. C. 3+ pitting edema. D. 4+ pitting edema.

Correct Answer is C

Explanation

The correct answer is Choice C: 3+ pitting edema.

Choice A rationale:

1+ pitting edema refers to mild pitting edema. It is characterized by a slight indentation that disappears rapidly. A measurement of 6 mm edema is beyond the scope of 1+ pitting edema.

Choice B rationale:

2+ pitting edema indicates moderate pitting edema. It is characterized by a deeper indentation that takes a few seconds to rebound. While 6 mm edema might be associated with 2+ pitting edema, it is not the most accurate description.

Choice C rationale:

3+ pitting edema signifies moderately severe pitting edema. It is characterized by a noticeable indentation that remains for a short duration. A measurement of 6 mm edema aligns with 3+ pitting edema, making it the correct choice.

Choice D rationale:

4+ pitting edema represents severe pitting edema. It is characterized by a deep indentation that persists for a significant amount of time. 6 mm edema is not typically associated with 4+ pitting edema.

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A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

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