A nurse is caring for a client who has recently died. Which of the following actions should the nurse take?
Remove the absorbent pads from underneath the client.
Place a pillow under the client's head.
Place the client in high-Fowler's position.
Remove the client's dentures
The Correct Answer is A
The nurse should remove the absorbent pads from underneath the client, place the client in a supine position with arms at the sides, close the client's eyes, and replace the client's dentures.
A pillow may be placed under the client's head for cosmetic purposes, but this is not a necessary action. High-Fowler's position is not appropriate for a deceased client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
An incident report is formal documentation used to report any unexpected or adverse events that occur during the course of patient care. It provides a record of the incident and helps identify areas for improvement in patient safety and quality of care. The incident report should include details about the error, the potential impact on the client, actions taken to address the error, and any necessary follow-up.
A nursing care plan is a document that outlines the client's nursing diagnoses, goals, interventions, and evaluations. It is not the appropriate place to document a medication error or incident.
The provider's progress notes are documentation made by the healthcare provider, typically documenting their assessments, diagnoses, treatment plans, and progress of the client. A medication error made by the nurse should not be documented in the provider's progress notes.
The controlled substance inventory record is a record used to track the dispensing and administration of controlled substances. While it is important to maintain accurate records of controlled substances, documenting a medication error in this record is not the appropriate place as it is primarily used for inventory management purposes
Correct Answer is B
Explanation
This response acknowledges the client's experience and shows a willingness to understand and address their concerns.
It opens up a dialogue about the hallucinations, allowing the nurse to gather more information and assess the client's current mental state. It also demonstrates empathy and support, which can help build trust between the nurse and the client.
Offering to discuss the voices with the client can also help in developing coping strategies and exploring potential interventions to manage the hallucinations effectively.
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