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 A
Explanation
The correct answer is choice A: "I know that I can change my advance directives if I need to in the future."
Choice A rationale:
This statement indicates an understanding of advance directives. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in case they become unable to make decisions themselves. It's important for clients to know that they can update or change their advance directives if their wishes or circumstances change over time.
Choice B rationale:
The statement that the health care surrogate will make decisions as soon as the power of attorney is signed is not accurate. Generally, a health care surrogate's authority to make decisions comes into effect when the primary individual is no longer able to make decisions themselves. Signing a power of attorney alone does not grant immediate decision-making power to the surrogate.
Choice C rationale:
The family generally cannot overrule the decisions made by a designated health care surrogate. Once an individual designates a surrogate and provides clear instructions through advance directives, the surrogate's decisions are legally binding and typically override the family's input.
Choice D rationale:
Advance directives are not universally valid across states. Laws and regulations regarding advance directives can vary significantly from state to state. It's important for clients to understand that if they relocate, they may need to update their advance directives to comply with the laws of the new state.
Correct Answer is D
Explanation
The correct answer is **d. Attach a humidifier to the base of the flow meter**.
Choice A rationale:
Keeping the side holes of the mask closed would restrict airflow and prevent the client from receiving the prescribed oxygen concentration. This action would be unsafe and should not be taken.
Choice B rationale:
Ensuring the reservoir bag is inflated on expiration is not necessary for a simple face mask. The reservoir bag is typically used with other oxygen delivery devices, such as a non-rebreather mask, to provide a higher concentration of oxygen. This action is not appropriate for the given scenario.
Choice C rationale:
Applying petroleum jelly to the client's nostrils is not a recommended action. Petroleum jelly can potentially cause irritation and dryness, which could lead to discomfort for the client. This action is not necessary for the safe administration of oxygen.
Choice D rationale:
Attaching a humidifier to the base of the flow meter is the appropriate action to ensure client safety. Humidifying the oxygen can help prevent drying of the client's airway and make the oxygen more comfortable to breathe. This is a recommended step when administering high-flow oxygen via a simple face mask.
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