A nurse is collecting data from a client who has heart failure and is taking furosemide.

Which of the following findings should indicate to the nurse that the medication is effective?

c. Diminished pulses on the affected extremity. This finding may indicate compromised circulation, which is

a serious complication that requires immediate intervention.

Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.

Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.

Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may

be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the affected extremity.

a. Location of the identification tag on the client's body: This is essential information that should be included in the documentation. It ensures that the deceased person is properly identified and helps prevent any mix-ups during subsequent processes, such as transferring the body to the morgue or a funeral home.

b-While this information is important, it's typically documented by the physician on the death certificate and is not generally part of the nurse's postmortem documentation.

c-The last set of vital signs is not usually required for postmortem documentation. Postmortem documentation focuses on the condition of the body and identification rather than the final vital signs, which are often irrelevant after death.

d-Advance directives should be reviewed before death and guide the care provided, but they are not part of postmortem documentation. A copy of the client's advance directives may also be included in their medical record but is not typically included in postmortem documentation.