A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

A. Increased urinary output. Furosemide is a loop diuretic that promotes diuresis by inhibiting sodium and water reabsorption in the kidneys. Increased urinary output indicates the medication is effectively reducing fluid volume, which is beneficial for clients with heart failure to decrease edema and pulmonary congestion.
B. Decreased BUN level. Blood urea nitrogen (BUN) levels can fluctuate due to hydration status and kidney function, but a decrease in BUN is not a primary indicator of furosemide’s effectiveness. Instead, BUN levels should be monitored for potential elevation, which could indicate dehydration or renal impairment as an adverse effect of the medication.
C. Decreased hemoglobin level. Furosemide does not directly affect hemoglobin levels. A decrease in hemoglobin may indicate anemia, which is not a desired or expected effect of diuretic therapy for heart failure.
D. Increased weight of 0.91 kg (2 lb). An increase in weight suggests fluid retention, which would indicate that heart failure is worsening rather than improving. Effective furosemide therapy should lead to weight reduction due to fluid loss, not weight gain.

A. "An incident report has been completed and sent to risk management." Incident reports are used for internal facility documentation and quality improvement but should not be mentioned in the medical record. Including this information could make the report discoverable in legal proceedings, which is why it should remain separate from the client’s medical documentation.
B. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement assigns blame without objective evidence and does not follow factual documentation principles. Medical records should include observable data, client statements, and assessments rather than subjective conclusions or assumptions about the cause of the fall.
C. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'" Including the client's direct statement ensures accurate, objective documentation. It provides firsthand information about the incident without making assumptions or assigning blame. Client statements should always be documented using quotation marks to maintain accuracy.
D. "The client does not appear to have any injuries resulting from the fall." This statement is subjective and may be misleading. A client could have internal injuries that are not immediately visible. Instead, the nurse should document a detailed physical assessment, such as "No visible injuries noted. Client denies pain or discomfort at this time."