A nurse is caring for an older adult client who has a hearing aid.
Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Choice A rationale

Placing an identification tag on the outside of the client's shroud is essential for proper identification, especially in cases requiring an autopsy. This practice ensures that the deceased person is accurately identified throughout the process and helps prevent any mix-ups or misidentifications.

Choice B rationale

Asking the assistive personnel to document the client's time of death is incorrect as it is the nurse's responsibility to document the time of death accurately in the medical records, not the assistive personnel's duty.

Choice C rationale

Wearing sterile gloves when cleaning the client's body is not necessary. Standard precautions and the use of non-sterile gloves are sufficient for postmortem care unless there are specific reasons requiring sterility, which is uncommon.

Choice D rationale

Removing the client's dentures and giving them to the client's family is incorrect for an autopsy case. Dentures should be left in place to maintain the integrity of the body and to ensure that all personal effects are accurately documented and managed.

Choice A rationale: The client’s respiratory rate of 10/min is below the normal range (12-20 breaths per minute). This suggests respiratory depression, which can be caused by opioid medications like morphine.

Choice B rationale: The client’s pulse oximetry reading of 88% on room air is lower than the normal range (95%-100%). This indicates hypoxemia, which may be due to respiratory depression from the morphine.

Choice C rationale: Although the blood pressure of 99/46 mm Hg is low, it might be acceptable for this client postoperatively. However, it does not require immediate intervention compared to the other choices.

Choice D rationale: The administration of morphine 10 mg subcutaneously needs further action because the client is showing signs of opioid overdose (e.g., respiratory depression, hypoxemia). This necessitates reassessment and potential adjustment of the medication dosage or frequency.