The nurse is reviewing the client's medical record.

Exhibits

The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

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."

• Calcium level: Decreased due to furosemide, a loop diuretic that increases calcium excretion in the urine, leading to mild hypocalcemia.
• Potassium level: Decreased due to furosemide, which causes potassium loss through diuresis. Lisinopril, an ACE inhibitor, can cause potassium retention, but in this case, the effect of furosemide dominates.
• Sodium level: Decreased due to furosemide-induced diuresis, which can lead to hyponatremia by excessive sodium loss.
• Edema: Improved due to furosemide, which promotes fluid removal and reduces volume overload associated with heart failure.
• Oxygen saturation: Improved due to carvedilol, which reduces heart failure symptoms by decreasing myocardial oxygen demand and improving cardiac output.
• Blood pressure: Lowered due to both carvedilol (a beta-blocker) and lisinopril (an ACE inhibitor), both of which reduce systemic vascular resistance.
• Weight: Decreased due to both carvedilol, which helps manage fluid retention over time in heart failure, and furosemide, which directly reduces fluid overload through diuresis.