A terminally ill client has just died in a hospital setting with the family members at the bedside. The health care provider is also present.
What should be the nurse's priority intervention as postmortem care begins?
Request that family members prepare the client's body for transfer to the funeral home.
Ensure that a death certificate has been completed by the physician.
Call for emergency assistance so that resuscitation procedures can begin.
Ask the family members if they would like to spend time alone with the client.
The Correct Answer is D
Choice A rationale
Requesting that family members prepare the body is inappropriate and culturally insensitive in most hospital settings. While some cultures may wish to participate in the washing or dressing of the deceased, the nurse should never assume this or place the burden of postmortem care entirely on grieving relatives. The nurse is responsible for the dignified handling of the body, and the priority is first addressing the emotional needs of the family present.
Choice B rationale
Ensuring the death certificate is completed is a necessary legal and administrative step in postmortem care, but it is not the immediate priority for the nurse at the bedside. The primary focus immediately following the death should be on the psychosocial and emotional support of the family members who are currently experiencing the loss. Administrative tasks can be managed once the family has been initially supported and offered time with their loved one.
Choice C rationale
Calling for emergency assistance to begin resuscitation is inappropriate because the patient is described as terminally ill and has already died. If the patient has a Do Not Resuscitate order or is in the end stages of a terminal disease, performing CPR would be contrary to their wishes and ethically unsound. The nurse's role in this moment is to provide a peaceful environment and support the survivors, rather than initiating futile medical interventions.
Choice D rationale
The priority intervention after a death is to provide compassionate, family-centered care. Offering the family time alone with the deceased allows them to begin the grieving process and say their final goodbyes in a private, respectful environment. This supports the emotional well-being of the survivors and honors the dignity of the patient. Once the family has had this opportunity, the nurse can then proceed with the technical aspects of postmortem body care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
In assist/control mode, every breath—whether initiated by the machine or the patient—is delivered at the full set tidal volume of 800 mL. If the patient is tachypneic at 22 breaths/min, they are receiving 22 high-volume breaths per minute. This excessive ventilation flushes out too much carbon dioxide from the blood. Since CO2 is an acid, a decrease in arterial CO2 (PaCO2 < 35 mmHg) leads to an increase in blood pH, resulting in respiratory alkalosis.
Choice B rationale
Metabolic acidosis is characterized by a low pH ( < 7.35) and a low bicarbonate level ( < 22 mEq/L). It is typically caused by the accumulation of metabolic acids, such as lactic acid or ketones, or the loss of bicarbonate through the kidneys or GI tract. Tachypnea on a ventilator in assist/control mode specifically affects the respiratory component of the acid-base balance by removing CO2, which does not directly cause a primary metabolic acid-base disturbance.
Choice C rationale
Respiratory acidosis occurs when there is alveolar hypoventilation leading to the retention of carbon dioxide (PaCO2 > 45 mmHg) and a decrease in pH. This would happen if the ventilator settings were too low or if the patient had significant dead space ventilation. In this scenario, the patient is over-ventilating by breathing 22 times per minute at a large tidal volume, which prevents the accumulation of CO2 and therefore makes respiratory acidosis impossible in this context.
Choice D rationale
Metabolic alkalosis involves a high pH (> 7.45) and an elevated bicarbonate level (> 26 mEq/L). This is usually caused by the loss of hydrogen ions through gastric suctioning or vomiting, or the excessive intake of bicarbonate. While the patient in the scenario will likely have an elevated pH, it is driven by the rapid respiratory removal of carbon dioxide rather than a metabolic shift in bicarbonate levels or fixed acid loss from the body.
Correct Answer is C
Explanation
Choice A rationale
Increased diaphragmatic excursion is not a typical indicator of excessively high intrathoracic pressure. In fact, high pressure from mechanical ventilation often limits the movement of the diaphragm because the lungs are over-inflated, potentially pushing the diaphragm downward and restricting its natural range of motion. Diaphragmatic excursion is a measure of the distance the diaphragm moves during inhalation and exhalation, and its assessment is more common in spontaneous breathing than in high-pressure mechanical ventilation monitoring.
Choice B rationale
A low-pressure alarm on a ventilator usually indicates a leak in the system, a disconnection of the tubing, or a cuff leak in the endotracheal tube. It signifies that the intended pressure is not being reached or maintained. Conversely, excessively high intrathoracic pressure would trigger a high-pressure alarm, which alerts the nurse to obstructions, coughing, biting the tube, or decreased lung compliance, rather than the low-pressure notification described in this particular choice.
Choice C rationale
Hypotension is a critical clinical alert for high intrathoracic pressure. When positive pressure ventilation increases pressure within the chest cavity, it compresses the superior and inferior vena cava. This compression reduces venous return to the right atrium, leading to decreased cardiac preload. Consequently, the stroke volume and cardiac output drop, resulting in a systemic decrease in blood pressure. Monitoring for hypotension is essential to prevent hemodynamic instability caused by excessive peak inspiratory pressures or peep.
Choice D rationale
A pulse oximetry value of 96 percent (normal range 95 to 100 percent) is a reassuring sign of adequate arterial oxygen saturation and does not indicate a problem with intrathoracic pressure. While high pressures can sometimes improve oxygenation by recruiting alveoli, a normal reading does not alert the nurse to the dangers of barotrauma or cardiovascular collapse associated with excessive pressure. Changes in blood pressure are much more sensitive and immediate indicators of the hemodynamic consequences of high pressure.
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