A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client before visitation by the family. Which of the following actions by the AP requires intervention by the nurse?
Gathering the client's personal belongings.
Removing the client's dentures.
Placing absorbent pads under the client's buttocks.
Closing the client's eyes.
The Correct Answer is B
The correct answer is choice B. Removing the client's dentures.
Choice A rationale:
Gathering the client's personal belongings is an appropriate action in the postmortem care process. This step allows the family to receive their loved one's belongings, contributing to a compassionate and respectful care process.
Choice B rationale:
Removing the client's dentures requires intervention by the nurse. In postmortem care, dentures should be left in place to maintain the natural appearance of the deceased's face and to ensure that the mouth and lips maintain their proper form.
Choice C rationale:
Placing absorbent pads under the client's buttocks is a common practice to manage any potential leakage of bodily fluids after death. This action helps maintain the cleanliness and dignity of the deceased individual.
Choice D rationale:
Closing the client's eyes is an appropriate action during postmortem care. It provides a peaceful appearance and shows respect for the deceased person.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."
Choice A rationale:
"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.
Choice B rationale:
"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.
Choice C rationale:
"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.
Choice D rationale:
"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.
Correct Answer is C
Explanation
The correct answer is Choice C: "Do you consume pork products?"
Choice C rationale: Islamic dietary laws, also known as Halal, prohibit the consumption of pork and its by-products. By asking the client about their consumption of pork products, the nurse demonstrates cultural sensitivity and ensures that the client's dietary preferences and religious practices are respected while under the facility's care.
Choice A rationale: Asking the client if they receive Holy Communion is not appropriate, as this practice is associated with Christianity rather than Islam. This question does not effectively address the client's religious preferences or needs in relation to their Islamic faith.
Choice B rationale: Inquiring about adherence to a kosher diet is not relevant, as this dietary practice is specific to Judaism and does not pertain to the Islamic faith. The nurse should be aware of the distinctions between religious practices when providing culturally competent care.
Choice D rationale: There is no general prohibition against blood transfusions in Islam. Islamic teachings generally permit medical treatments, including blood transfusions, when deemed necessary for the well-being and preservation of life. Asking the client about opposition to blood transfusions would not be the most effective way to clarify their religious preferences in the context of Islam.
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