A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider? (Click on the tabs belowfor additional information about the client. There are tabs that contain separate categories of data.)

Exhibits Here

The correct answer is choice C. Holding the client’s eyes shut for a few seconds.

This is because the eyes of a deceased client do not close naturally and may remain open after death. Holding them shut for a few seconds helps to keep them closed and prevent drying of the corneas.

This also gives a more peaceful appearance to the client’s body for the family visit.

Choice A is wrong because crossing the client’s arms across their chest is not a standard postmortem care procedure. It may also interfere with the placement of identification tags on the wrists.

Choice B is wrong because placing the client in a high-Fowler’s position is not necessary or appropriate for postmortem care. The client should be placed in a supine position with the head of the bed elevated to prevent livor mortis (purple discoloration of the skin) on the face.

Choice D is wrong because removing the client’s dentures from their mouth is not recommended for postmortem care. The dentures should be left in place to maintain the shape of the face and prevent the jaw from dropping.

Normal ranges are not applicable for this question as it does not involve any physiological measurements.

Choice A option

Fibrinogen level: Fibrinogen is a protein involved in the blood clotting process, but in this case, it is not appropriate because is not the primary laboratory test used to monitor warfarin therapy. Monitoring fibrinogen levels is more relevant in assessing bleeding disorders or certain medical conditions.

Choice B option

PTT (Partial Thromboplastin Time): PTT is another laboratory test used to evaluate blood clotting function, particularly the intrinsic pathway of the clotting cascade. PTT is not routinely used to monitor warfarin therapy; it is more commonly used to monitor other anticoagulant medications like heparin.

Choice C option

The nurse should plan to report the client's INR (International Normalized Ratio) to obtain a prescription for the client's daily warfarin. INR is a critical laboratory test used to monitor the effectiveness and safety of warfarin therapy.

Warfarin is an anticoagulant medication commonly prescribed to prevent and treat blood clots. It works by interfering with the body's ability to use vitamin K to form blood clots. Monitoring the INR is essential because it indicates how long it takes for the blood to clot, and it helps determine if the client's warfarin dosage needs adjustment to achieve the desired level of anticoagulation.

Choice D option

Platelet count: Platelet count is essential to assess the number of platelets in the blood, which are crucial for normal clotting. However, platelet count monitoring is not the primary focus when prescribing warfarin. It is typically used to evaluate thrombocytopenia (low platelet count) or other conditions affecting platelet function.