A nurse is completing postmortem documentation for a client.
Which of the following information should the nurse include in the documentation?
Cause of the client's death.
Last set of the client's vital signs.
Copy of the client's advance directives.
Location of the identification tag on the client's body.
The Correct Answer is D
The correct answer is: d. Location of the identification tag on the client’s body.
Choice A reason: The cause of the client’s death is determined by a physician or a medical examiner and is not typically documented by nurses in postmortem documentation. The cause of death is a medical determination that involves a complex process, including examination and possibly an autopsy.
Choice B reason: The last set of the client’s vital signs is relevant prior to death and is part of the end-of-life documentation. However, once the client has passed away, recording vital signs is no longer applicable and is not included in postmortem documentation.
Choice C reason: A copy of the client’s advance directives is an important document that outlines the client’s wishes regarding medical treatment and interventions. While it is crucial before the client’s death, it does not need to be included in postmortem documentation, as it serves no purpose after death.
Choice D reason: The location of the identification tag on the client’s body is a critical piece of information that must be included in postmortem documentation. This ensures that the body is correctly identified throughout the postmortem process, including during transfer to a mortuary or funeral home.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"This medication can increase your risk for sunburn." Ciprofloxacin, a fluoroquinolone antibiotic, can increase the risk of sunburn and photosensitivity reactions. Patients taking this medication should be advised to use sunscreen, wear protective clothing, and avoid excessive sun exposure to prevent sunburn.
Choice B rationale:
"Take an antacid if the medication causes gastrointestinal upset." Ciprofloxacin should not be taken with antacids or other products containing calcium, magnesium, aluminum, or iron, as these can interfere with its absorption. Therefore, advising the patient to take an antacid with ciprofloxacin is incorrect.
Choice C rationale:
"Restrict your daily fluid intake while taking this medication." There is no need to restrict fluid intake while taking ciprofloxacin. In fact, it is important for patients to stay well-hydrated to prevent potential side effects like crystalluria. Adequate fluid intake helps dilute the urine and reduce the risk of crystal formation.
Choice D rationale:
"Expect to experience diarrhea while taking this medication." Diarrhea can be a side effect of ciprofloxacin, but it is not something patients should necessarily expect. While gastrointestinal upset is a known side effect, not everyone who takes the medication will experience diarrhea. Patients should be advised to report any severe or persistent diarrhea to their healthcare provider.
Correct Answer is ["A","B","C"]
Explanation
Answer is: A, B, and C.Respiratory rate, oxygen saturation level, and heart rate are the three findings that require immediate follow-up. These findings indicate that the client is experiencing respiratory distress and possible complications of pneumonia, such as sepsis and cardiac arrhythmia. The client needs prompt intervention to improve oxygenation, stabilize the heart rhythm, and treat the infection.
- Statement D is wrong because the chronic health condition of the client (Parkinson’s disease) is not an acute problem that needs immediate attention. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease.
- Statement E is wrong because the current level of consciousness of the client (alert and oriented to self) is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation.
- Statement F is wrong because the tremors of the client are likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures.
Normal ranges for the vital signs and arterial blood gas are as follows:
- Respiratory rate: 12 to 20 breaths per minute
- Oxygen saturation level: 95% to 100%
- Heart rate: 60 to 100 beats per minute
- Blood pressure: less than 120/80 mmHg
- Temperature: 36.5°C to 37.2°C
- Arterial blood gas: pH 7.35 to 7.45, PaO2 80 to 100 mmHg, PaCO2 35 to 45 mmHg, HCO3 22 to 26 mEq/L
Correct answer is: A, B, and C.
Choice A rationale: Respiratory rate is 28 breaths per minute and labored. This is above the normal range of 12 to 20 breaths per minute and indicates that the client is experiencing respiratory distress. Respiratory distress can lead to hypoxia, tissue damage, and organ failure. Therefore, this finding requires immediate follow-up to improve the client’s oxygenation and ventilation.
Choice B rationale: Oxygen saturation level is 88% on room air. This is below the normal range of 95% to 100% and indicates that the client is hypoxemic. Hypoxemia can result from pneumonia, which causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. Hypoxemia can also cause dysrhythmias, confusion, and cyanosis. Therefore, this finding requires immediate follow-up to administer supplemental oxygen and monitor the client’s response.
Choice C rationale: Heart rate is 110 beats per minute and irregular. This is above the normal range of 60 to 100 beats per minute and indicates that the client has tachycardia and atrial fibrillation. Tachycardia can result from hypoxia, fever, infection, dehydration, or anxiety. Atrial fibrillation is a type of cardiac arrhythmia that causes irregular and rapid contractions of the atria, reducing the cardiac output and increasing the risk of thromboembolism. Therefore, this finding requires immediate follow-up to identify and treat the underlying cause, stabilize the heart rhythm, and prevent complications.
Choice D rationale: Chronic health condition is Parkinson’s disease. This is not an acute problem that requires immediate follow-up. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease, as they can affect the client’s mobility, safety, and quality of life.
Choice E rationale: Current level of consciousness is alert and oriented to self. This is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation, as they can result from hypoxia, infection, or medication side effects.
Choice F rationale: Tremors are in both hands. This is likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures, such as warm blankets, massage, or relaxation techniques.
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