A nurse is performing postmortem care for a client who has just died. Which of the following actions should the nurse take?
Close the client's eyes with paper tape.
Identify the client using two identifiers.
Remove the client's pillow to prevent discoloration of the face.
Remove the client's dentures.
The Correct Answer is B
A. Close the client's eyes with paper tape: The eyes should be gently closed manually or by placing a small rolled gauze over the eyelids; paper tape can irritate the skin or damage fragile tissue and is not recommended.
B. Identify the client using two identifiers: Proper identification using two identifiers, such as name and medical record number, is essential in postmortem care to ensure accurate handling of the body, compliance with legal requirements, and prevention of errors.
C. Remove the client's pillow to prevent discoloration of the face: The pillow may be adjusted for comfort and positioning, but removing it to prevent discoloration is not standard practice. Discoloration due to livor mortis is a natural process and cannot be prevented by pillow placement.
D. Remove the client's dentures: Dentures should remain in place during postmortem care to maintain facial structure and natural appearance for viewing by family. Removal is only necessary if required for identification or specific postmortem procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Peer pressure: Peer pressure is considered an external stressor because it originates from outside influences, such as social interactions and the expectations of others. It impacts behavior but is not generated internally.
B. Death of a family member: The loss of a loved one is an external stressor since it arises from an environmental and situational event outside the individual’s control. The stress reaction follows the external occurrence.
C. Fear of medical test results: Fear is an internal stressor because it originates from the individual’s own thoughts, emotions, and perceptions. It reflects how the person interprets and responds to a situation, even before external outcomes are known.
D. Job transfer to another city: A job transfer is an external stressor because it is an environmental change imposed on the individual. The stress arises from circumstances in the person’s surroundings rather than internal feelings.
Correct Answer is D
Explanation
A. 15°: This angle is used for intradermal injections, such as a tuberculin skin test, where the medication is deposited just under the epidermis. It would not allow the needle to reach the muscle layer, making it inappropriate for intramuscular administration.
B. 60°: An angle of 60° is not a standard technique for any specific injection type. At this angle, the medication would likely end up in the subcutaneous tissue instead of the muscle, leading to improper absorption and reduced effectiveness.
C. 45°: This angle is appropriate for subcutaneous injections, such as insulin, when a shorter needle is used or in thin clients. It does not penetrate deeply enough to reach the muscle tissue for intramuscular medication administration.
D. 90°: A 90° angle ensures the needle penetrates through the subcutaneous tissue and into the muscle, which is necessary for intramuscular injections. This angle allows the medication to be deposited directly into the muscle for proper absorption and therapeutic effect.
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