A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

Instruct the family to leave prior to cleaning the client's body.

Encourage the family to express their feelings of loss.

Limit the amount of time the family spends in the client's room.

Ask the family not to touch the client's body.

Answer and Explanation

The Correct Answer is B

The correct answer is B. The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.

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Correct Answer is B

Explanation

The correct answer is B.

Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action accordingto the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.

A. Collect a sterile specimen from the urinary drainage bag. B. Secure the tubing with adhesive tape to the lower abdomen. C. Instruct the client to hold the drainage bag at waist height when ambulating. D. Coil the tubing on the bed above the collection bag.

Correct Answer is B

Explanation

A.Urinary specimens collected from the bag may be contaminated and do not provide a reliable sample. A sterile specimen should be collected from the catheter port if needed.

B.In male patients secure catheter to upper thigh (with penis directed downward) or abdomen (with penis directed toward chest), allowing enough slack to prevent tension.

C.Guidelines recommend that the urinary drainage bag be kept below the level of the bladder, typically lower than the waist, to ensure proper urine flow and prevent reflux.

D.Coiling the tubing can impede proper drainage, leading to potential complications like urinary retention and infection.

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A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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