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 B
Explanation
The correct answer is: B. Latex.
Choice A reason: Allergy to eggs is primarily a concern when it comes to vaccinations, such as the influenza vaccine, which may contain egg protein. In the context of IV therapy, egg allergies are not typically associated with direct contraindications or precautions. However, it’s important to note that some medications or vaccines may contain egg proteins, which could be relevant in certain medical procedures, but not usually in standard IV therapy.
Choice B reason: Latex allergies are particularly relevant in a hospital setting where latex is commonly found in various medical supplies, including gloves, catheters, and IV tubing. A latex allergy can cause severe reactions, including anaphylaxis, which is a life-threatening condition. Therefore, it is crucial for healthcare providers to be aware of a patient’s latex allergy to avoid exposure during medical procedures, including IV therapy.
Choice C reason: Seafood allergies are generally related to the ingestion of seafood and do not typically pose a risk in the context of IV therapy. The concern about iodine in contrast media, which is sometimes mistakenly linked to seafood allergies, is not relevant to standard IV therapy solutions.
Choice D reason: Bee sting allergies are significant when a patient is exposed to bee venom, which can cause anaphylaxis. In the context of IV therapy, a bee sting allergy is not typically a concern unless the therapy involves venom immunotherapy or the patient has had a recent bee sting that might complicate their medical condition.
Correct Answer is D
Explanation
The correct answer is choice D. The client has tenderness and warmth in their calf.
Choice A rationale:
The client's self-reported incisional pain level of 7 on a scale of 0 to 10 is important information to assess postoperative recovery, but it is not the priority finding to report among the choices. Pain management is crucial, but potential complications that could be more urgent should be addressed first.
Choice B rationale:
Increased nausea and chills are concerning postoperative findings, but they could be related to the body's response to surgery, anesthesia, or pain medications. While these symptoms should be monitored and managed, they are not as high-priority as potential complications involving the calf.
Choice C rationale:
An oral temperature of 38.5°C (101.3°F) indicates a fever and is also a concerning finding in the postoperative period. Infection could be a possible cause, and the provider should be informed. However, compared to tenderness and warmth in the calf, which could suggest deep vein thrombosis (DVT), the fever is of slightly lower priority.
Choice D rationale:
Tenderness and warmth in the calf are the priority findings to report. These symptoms raise concern about the possibility of deep vein thrombosis (DVT), a serious complication after surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the legs. If left untreated, it can lead to a pulmonary embolism, a life-threatening condition where the clot travels to the lungs. Immediate assessment and intervention are necessary to rule out or address this potentially critical complication.
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