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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

Answer and Explanation

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.

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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.

A. Tortuous veins B. Clammy skin C. Bradycardia D. Calf swelling

Correct Answer is D

Explanation

Rationale:

A. Tortuous veins are a common finding in clients with deep-vein thrombosis and may not require immediate reporting.

B. Clammy skin may be a sign of poor circulation but is not specific to deep-vein thrombosis and may not require immediate reporting.

C. Bradycardia is not typically associated with deep-vein thrombosis and may not require immediate reporting.

D. Calf swelling is a common sign of deep-vein thrombosis and should be reported to the provider immediately.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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