A nurse is reinforcing teaching with a client who is starting digoxin therapy to treat heart failure. The nurse should reinforce with the client that which of the following adverse effects is a possible indication of digoxin toxicity and should be reported to the provider?

Choice A Reason:

The cause of death is determined and documented by the physician or medical examiner, not the nurse. Including this in the postmortem documentation by the nurse would be inappropriate as it is not within the nurse's scope of practice to make this determination.

Choice B Reason:

While the nurse may document the last set of vital signs before death, this is typically recorded in the patient's medical record at the time the vital signs are taken, not specifically in postmortem documentation. The focus of postmortem documentation is on the events and conditions after the death has been confirmed.

Choice C Reason:

The location of the identification tag is crucial in postmortem documentation to ensure proper identification of the deceased. This information helps in maintaining the integrity and identification of the body during transportation and handling by the mortuary or funeral home.

Choice D Reason:

Advance directives are part of the client's medical record and are used to guide care decisions while the client is alive. They are not typically included in postmortem documentation, as they pertain to the client's wishes regarding treatment prior to death, not after. The original documents should remain in the client's file.

Choice A Reason:

Changing a central venous catheter dressing for a client who is receiving IV therapy is correct. Sterile gloves should be used when performing procedures that involve the manipulation of sterile or aseptic areas, such as changing the dressing on a central venous catheter. Maintaining the sterility of the catheter site is crucial to prevent infections in clients receiving IV therapy through central lines.

Choice B Reason:

Instilling an ophthalmic ointment for a client with a corneal abrasion involves applying a medication to the eye is incorrect. While it's important to use clean technique and maintain good hand hygiene, it does not require sterile gloves.

Choice C Reason:

Inserting an NG (nasogastric) tube for enteral feedings is a clean procedure, not a sterile one. Clean gloves are typically used to maintain cleanliness and reduce the risk of infection, but full sterile technique is not necessary.

Choice D Reason:

Administering an IM (intramuscular) injection also does not require sterile gloves. Clean gloves should be used to maintain infection control, but full sterile technique is not needed for routine IM injections.