A nurse is caring for a client who just died. The client's family requests to perform the postmortem care. Which of the following responses should the nurse make?

"You will have to sign a release form to perform the care yourself."

"I will assist you in any way I can during this process."

"This care takes place after the client leaves the facility."

"A licensed health care worker must perform postmortem care."

Answer and Explanation

The Correct Answer is B

A. "You will have to sign a release form to perform the care yourself.": There is no standard legal release form required for family involvement in postmortem hygiene.

B. "I will assist you in any way I can during this process.": This is a culturally sensitive and therapeutic response. Allowing the family to participate in postmortem care can provide closure and honor religious or personal rituals.

C. "This care takes place after the client leaves the facility.": Postmortem care is performed immediately after death in the facility to prepare the body for the family to view and for transport.

D. "A licensed health care worker must perform postmortem care.": While the nurse is responsible for the overall process, there is no law preventing family members from assisting or performing the care themselves if they wish.

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Correct Answer is C

Explanation

A. Tongue depressor: This is typically used for oral examinations or as a splint for small digits, not for wound assessment.

B. Syringe: While a syringe might be used for wound irrigation, it is not the primary tool for collecting data or measuring the wound's physical characteristics.

C. Cotton-tipped applicator: A stage 4 pressure injury involves full-thickness tissue loss with exposed bone, tendon, or muscle. A cotton-tipped applicator is used to measure the depth of the wound and to check for tunneling or undermining.

D. Adhesive tape: This is used to secure a dressing but does not assist in the data collection/assessment of the wound itself.

A. "Once I sign the consent form, I cannot change my mind about having the procedure." B. "I will be told about alternative procedures before I'm asked to sign the consent form." C. "The consent form will include the estimated time for my recovery from the procedure." D. "My nurse is responsible for obtaining informed consent."

Correct Answer is B

Explanation

A. "Once I sign the consent form, I cannot change my mind.": A client has the right to withdraw consent and refuse treatment at any time, even after the form is signed.

B. "I will be told about alternative procedures before I'm asked to sign.": Informed consent requires that the client understands the risks, benefits, and alternatives to the procedure.

C. "The consent form will include the estimated time for my recovery.": While recovery may be discussed, the consent form specifically focuses on the procedure, risks, and provider performing it, rather than a timeline for recovery.

D. "My nurse is responsible for obtaining informed consent.": The provider (surgeon) is responsible for explaining the procedure and obtaining consent. The nurse’s role is to witness the signature and ensure the client is competent.

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A nurse is caring for a client who just died. The client's family requests to perform the postmortem care. Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

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