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 C
Explanation
Rationale:
A. Cleansing the client's outer ear with isopropyl alcohol to remove wax is not recommended because it can cause irritation and dryness.
B. Pulling the client's pinna downward and back is an incorrect technique for instilling otic medication in an adult client. An adult ear should be pulled upwards and backwards.
C. Holding the ear dropper 1 cm (0.5 in) from the client's ear is accurate.
D. Requesting the client remain supine for 10 min following administration is not necessary and may not be practical, instead the client should lie on the contralateral side.
Correct Answer is B
Explanation
Rationale:
A. This response addresses the client's desire to have family visits but does not directly address the client's concerns about end-of-life care.
B. Asking the client to express their expectations about activities related to the end-of-life allows the nurse to understand the client's wishes and concerns and to provide appropriate support.
C. This response addresses the client's need for pain management but does not directly address the client's concerns about end-of-life care.
D. This response addresses the client's need for spiritual support but does not directly address the client's concerns about end-of-life care.
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