A nurse is caring for a client.

Exhibit 1

Medical History

0800:

Client has a history of hyperlipidemia, rheumatoid arthritis, and hypertension.

Client has a BMI of 32.

Client has a family history of colon cancer.

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for heart disease? (Select all that apply.)

A. Asking the family if they wish to assist in washing the client's body:

This is an important first step because it respects the family's cultural or religious practices and allows them to participate in the care of their loved one if they choose. It sets the tone for sensitive and respectful postmortem care.

B. Removing the client's dentures for their family to keep:

Dentures are usually leftin the mouth tomaintain facial shape.However, this action is not the first priority.

C. Leaving the client's eyes open until the family views the body:

It is generally recommended to gently close the client's eyes after death as part of the postmortem care process. Leaving the eyes open might be distressing for the family, so this action should not be performed first.

D. Turn overhead lights to a bright setting.

Bright lighting may not be comforting for the family or create a peaceful environment. Dim or soft lighting is usually preferred to create a calming atmosphere during this sensitive time. Therefore, this is not the first action the nurse should take.

A. Administer the client's insulin dose using a tuberculin syringe:

While using an appropriate syringe for insulin administration is important, ensuring the accuracy of the dosage precedes the actual administration. Therefore, verifying the dose takes precedence over selecting the syringe.

B. Use a filter needle when withdrawing medication from the multidose vial:

While using a filter needle can be beneficial to prevent contamination, ensuring the correct dosage is more critical in preventing adverse effects associated with incorrect insulin administration.

C. Verify the dose of insulin with another nurse once it is prepared.

Before administering insulin to a client with type 1 diabetes, it is essential to ensure accuracy in dosage. Verifying the dose with another nurse helps minimize the risk of errors, ensuring the client receives the correct amount of insulin. This step aligns with the principle of double-checking medications for safety, especially in critical situations like insulin administration.

D. Mix the client's long-acting and rapid-acting insulin dose in one syringe:

Mixing different types of insulin in one syringe is not standard practice unless specifically instructed by a healthcare provider. This step should be performed only if explicitly ordered an