A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client before visitation by the family. Which of the following actions by the AP requires intervention by the nurse?
Gathering the client's personal belongings.
Removing the client's dentures.
Placing absorbent pads under the client's buttocks.
Closing the client's eyes.
The Correct Answer is B
The correct answer is choice B. Removing the client's dentures.
Choice A rationale:
Gathering the client's personal belongings is an appropriate action in the postmortem care process. This step allows the family to receive their loved one's belongings, contributing to a compassionate and respectful care process.
Choice B rationale:
Removing the client's dentures requires intervention by the nurse. In postmortem care, dentures should be left in place to maintain the natural appearance of the deceased's face and to ensure that the mouth and lips maintain their proper form.
Choice C rationale:
Placing absorbent pads under the client's buttocks is a common practice to manage any potential leakage of bodily fluids after death. This action helps maintain the cleanliness and dignity of the deceased individual.
Choice D rationale:
Closing the client's eyes is an appropriate action during postmortem care. It provides a peaceful appearance and shows respect for the deceased person.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["13.6"]
Explanation
The correct answer is 13.6 kg.
To convert pounds to kilograms, the formula is weight in pounds divided by 2.2. Given the child's weight is 30 lb, the calculation would be 30 / 2.2 ≈ 13.64 kg. Rounding to the nearest tenth gives us 13.6 kg.
Correct Answer is A
Explanation
The correct answer is choice A: "Complained about having incisional pain."
Choice A rationale:
Documenting a client's complaints about pain, especially incisional pain, is crucial in an electronic health record. Pain assessment and management are essential aspects of client care, and including this information helps to track the client's pain level, the effectiveness of pain interventions, and any changes in their condition over time.
Choice B rationale:
While it's important to monitor fluid intake and output, stating that the client "Voided adequate amounts through the shift" might be relevant to the client's overall condition but lacks specific information. It doesn't address the reason for the assessment, and the focus should be on the client's immediate care needs and responses.
Choice C rationale:
Noting that the client "Became short of breath when ambulating" is significant for documenting any potential signs of respiratory distress during activity. This information provides valuable insights into the client's ability to tolerate physical exertion and might indicate a need for further assessment or interventions.
Choice D rationale:
Documenting that the client "Appeared to be sleeping while in bed" might not offer significant clinical information unless there is a specific reason for noting the client's sleep patterns. Sleep is an important aspect of recovery, but this choice lacks the context needed to make it a priority entry in the documentation.
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