A nurse is assisting with the postmortem care of a client whose partner is at the bedside. Which of the following actions should the nurse take?

Choice A reason: Client instructed on self-care needs is not a specific or accurate documentation. The nurse should include the details of the instruction, such as the topics covered, the teaching methods used, the client's response, and the evaluation of learning.

Choice B reason: Oral temperature elevated at 0800 is a specific and accurate documentation. The nurse should include the vital signs and any abnormal findings, such as fever, in the client's health record. The nurse should also report the elevation to the provider and monitor the client for signs of infection.

Choice C reason: Episiotomy approximated, 3 cm (1.18 in) in length is not a specific or accurate documentation. The nurse should include the type, location, and degree of the episiotomy, as well as the condition of the wound, the presence of edema, erythema, or drainage, and the interventions performed.

Choice D reason: Client drank adequate amounts of fluid with meals is not a specific or accurate documentation. The nurse should include the exact amount and type of fluid intake, as well as the output, in the client's health record. The nurse should also assess the client for signs of dehydration or fluid overload.

Choice A reason: You do not need to have advance directives in place in order to refuse recommended treatment. Advance directives are legal documents that allow you to express your wishes for your health care in case you are unable to communicate or make decisions for yourself. You have the right to accept or refuse any treatment at any time, as long as you are competent and informed.

Choice B reason: An attorney is not needed in order for you to name a designee in your health care proxy. A health care proxy is a type of advance directive that allows you to appoint a person to make health care decisions for you if you are unable to do so. You can choose anyone you trust, such as a family member or a friend, as your designee. You do not need a lawyer to complete a health care proxy form, but you need to sign it in front of two witnesses.

Choice C reason: You can decline to have certain medical procedures performed in your living will. A living will is another type of advance directive that allows you to state your preferences for life-sustaining treatments, such as CPR, artificial ventilation, or feeding tubes. You can specify which treatments you want or do not want, and under what circumstances. You can also include your values and beliefs about your quality of life and end-of-life care.

Choice D reason: A living will cannot be an oral statement that you agree upon with your provider. A living will must be a written document that is signed by you and witnessed by two people. An oral statement may not be legally valid or enforceable, and it may not reflect your current wishes. You should review and update your living will periodically, and share it with your provider, your designee, and your family.