A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources, which of the following findings indicates the information likely contains credible medical information?

Explanation

Correct answer: A

A.It is important to document the location of the identification tag to ensure proper identification of the body. This is crucial for legal and administrative purposes and helps prevent any potential confusion or misidentification.

B.A copy of the client's advance directivesis an important document for healthcare providers to have during the client's care but is not typically included in the post-mortem documentation. Advance directives are typically stored separately and are more relevant to the client's care while they are alive.

C. Cause of the client's death: Determining and documenting the cause of death is typically the responsibility of the attending physician or medical examiner, not the nurse.

D.The last set of the client's vital signs in (option D) may be relevant during the client's care and treatment but may not be specifically included in the post-mortem documentation. The focus of post-mortem documentation is usually on aspects such as the cause of death, time of death, interventions performed, and any significant findings related to the client's condition or autopsy.

Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.

Incorrect:

B- Limit documentation to subjective information: This is an incorrect action to take.

Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.

C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.

D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.