A nurse is caring for a terminally ill client on hospice who passed away during the shift. Select the "3" postmortem care actions the nurse should take?
Lay the client's head flat.
Consider any cultural, religious, or social practices of the client that would impact postmortem care.
Dim the lights and minimize noise to provide a calm environment.
Verify the provider has certified and documented death of the client.
Tell the family to leave the room while you prepare the body.
Correct Answer : B,C,D
A. Lay the client's head flat. Keeping the client’s head slightly elevated, rather than flat, helps prevent discoloration from blood pooling in the face. Positioning the body appropriately is part of postmortem care, but laying the head completely flat is not recommended.
B. Consider any cultural, religious, or social practices of the client that would impact postmortem care. Respecting cultural and religious practices is essential in providing compassionate end-of-life care. Some cultures have specific rituals or beliefs regarding handling the body, and the nurse should accommodate these whenever possible.
C. Dim the lights and minimize noise to provide a calm environment. Creating a peaceful environment is important for both the family and staff. A calm, quiet setting allows the family to grieve and say their final goodbyes in a respectful and dignified manner.
D. Verify the provider has certified and documented death of the client. Before proceeding with postmortem care, the nurse must ensure the provider has officially confirmed and documented the time of death. This is a legal requirement and a crucial step in the process.
E. Tell the family to leave the room while you prepare the body. Forcing the family to leave is inappropriate and insensitive. Many families want to be present during postmortem care or take part in rituals. The nurse should offer them the option to stay or leave based on their preference.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Use pictures. Visual aids enhance comprehension, especially for clients with limited English proficiency. Pictures, diagrams, and illustrations help convey important information when language barriers exist.
B. Use materials written at a twelfth-grade level. This is inappropriate because most health education materials should be written at a fifth- to sixth-grade reading level to ensure accessibility. Higher reading levels may be too complex for many clients, particularly those with limited health literacy.
C. Provide a variety of educational materials. While multiple formats (e.g., videos, pamphlets) can be helpful, simply offering a variety does not ensure comprehension. The materials must be tailored to the client’s language and literacy level.
D. Choose materials that include culturally relevant information and examples. Cultural relevance improves engagement and understanding. Materials should reflect the client’s cultural background, beliefs, and values to make the information more meaningful.
E. Use materials written in the client's spoken language. Providing materials in the client’s primary language ensures better understanding. When possible, professional medical interpreters should also be used to clarify any uncertainties.
Correct Answer is C
Explanation
A. Spread client care activities throughout the shift. Frequent interruptions can contribute to sensory overload by preventing rest and relaxation. Instead, clustering care activities minimizes disturbances and helps create a calmer environment.
B. Keep the door to the client's room open. An open door can increase noise levels and exposure to environmental stimuli, such as hallway conversations and alarms, worsening sensory overload. Keeping the door closed or partially closed can help reduce unnecessary stimuli.
C. Provide the client with earplugs. Earplugs help block out excessive noise from medical equipment, conversations, and alarms, reducing auditory overstimulation. This intervention allows the client to rest and promotes a more comfortable healing environment.
D. Encourage visitors throughout the day. While social interaction is important, excessive visits can contribute to sensory overload. Limiting and scheduling visitor times appropriately helps balance emotional support with the need for rest and recovery.
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