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 ["B","C","E"]
Explanation
A. Wear an N95 mask when caring for the client: An N95 mask is necessary for airborne infections such as tuberculosis or measles. Pneumonia caused by typical bacteria or viruses is spread by droplets, so a surgical mask is sufficient, not an N95.
B. Place the client in a private room: Clients with pneumonia should be placed in a private room to prevent transmission of infectious droplets to others, especially those who are immunocompromised or at higher risk for respiratory infections.
C. Place the client on droplet isolation precautions: Pneumonia spreads through large respiratory droplets from coughing or sneezing. Droplet precautions include wearing a surgical mask within 3 feet of the client and limiting close contact exposure.
D. Assign client to a negative air pressure room: A negative air pressure room is required for airborne precautions, not droplet infections like pneumonia. It is unnecessary and would reserve specialized rooms for conditions requiring them.
E. Ensure the client wears a mask when outside their room: Having the client wear a surgical mask while leaving the room helps contain respiratory secretions and prevents droplet transmission to others in hallways or procedure areas.
Correct Answer is A
Explanation
A. Determine the source of the client's stress: The first step in managing insomnia related to stress is assessing and identifying the underlying cause. Understanding the source allows the nurse to tailor interventions effectively and ensures that care addresses the root of the problem rather than just the symptoms.
B. Instruct the client to turn off their TV just before they go to bed: Reducing screen time before sleep is helpful in promoting rest, but this is a specific behavioral strategy. It should follow an assessment of the client’s stressors and sleep patterns to be applied appropriately.
C. Encourage the client to listen to soft music at the onset of stress: Relaxation techniques such as music therapy can aid stress reduction, but they are supportive measures. Without assessing the client’s unique stressors first, these interventions may not fully address the insomnia.
D. Advise the client to exercise daily in the morning: Morning exercise can improve sleep quality and reduce stress, but it is a long-term strategy. The nurse must first explore the client’s stress triggers to ensure that interventions are individualized and effective.
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