A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

The correct answer is: d. Location of the identification tag on the client’s body.

Choice A reason: The cause of the client’s death is determined by a physician or a medical examiner and is not typically documented by nurses in postmortem documentation. The cause of death is a medical determination that involves a complex process, including examination and possibly an autopsy.

Choice B reason: The last set of the client’s vital signs is relevant prior to death and is part of the end-of-life documentation. However, once the client has passed away, recording vital signs is no longer applicable and is not included in postmortem documentation.

Choice C reason: A copy of the client’s advance directives is an important document that outlines the client’s wishes regarding medical treatment and interventions. While it is crucial before the client’s death, it does not need to be included in postmortem documentation, as it serves no purpose after death.

Choice D reason: The location of the identification tag on the client’s body is a critical piece of information that must be included in postmortem documentation. This ensures that the body is correctly identified throughout the postmortem process, including during transfer to a mortuary or funeral home.

Choice A rationale:

Decreased platelets are not typically an indicator of infection. Platelet levels may decrease in conditions like thrombocytopenia, but they are not a specific indicator of infection.

Choice B rationale:

Increased erythrocyte sedimentation rate (ESR) is an indicator of infection. An elevated ESR is a nonspecific marker of inflammation in the body, which can be seen in response to infection, among other conditions.

Choice C rationale:

Decreased hemoglobin is not typically an indicator of infection. Hemoglobin levels may decrease in conditions like anemia, but they are not a specific indicator of infection.

Choice D rationale:

Increased iron levels are not typically an indicator of infection. Iron levels can vary for various reasons, but they are not a direct marker of infection.