A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
Washing the client's face
Gathering the client's personal belongings
Closing the client's eyes
Removing the client's dentures from their mouth
The Correct Answer is D
Rationale:
A. Washing the client's face is part of postmortem care and is appropriate.
B. Gathering the client's personal belongings is part of postmortem care and is appropriate.
C. Closing the client's eyes is part of postmortem care and is appropriate.
D. Removing the client's dentures from their mouth is not part of postmortem care and may be distressing for the family. The nurse should intervene and ensure the dentures are left in place.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.
B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.
C. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.
D. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.
Correct Answer is ["A","B","C","D"]
Explanation
A. The client has hypertension and high sodium levels, indicating fluid retention, so a diuretic may be prescribed to help manage these conditions.
B. The client reports difficulty sleeping without drinking several beers a night, indicating a potential alcohol problem. Limiting alcohol intake is a common recommendation for clients with this issue.
C. The client has elevated LDL cholesterol, indicating high-fat intake, so limiting fat intake can help manage this.
D. The client has elevated sodium levels, so reducing sodium intake can help manage this.
E. There is no indication for an antibiotic prescription based on the client's symptoms and lab results.
F. There is no indication of high potassium levels, so limiting foods high in potassium is not necessary.
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