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.

Answer and Explanation

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.

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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.

A. "You will need to look to the side when you put the drops in your eye." B. "You should put the drops directly in the center of your eyeball." C. "You should cleanse your eye from the inner to the outer edge prior to putting in the drops." D. "You should avoid pressing on your tear duct after putting the drops in your eye.”

Correct Answer is C

Explanation

The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”

Choice A rationale:

Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.

Choice B rationale:

Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.

Choice C rationale:

Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.

Choice D rationale:

Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.

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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?

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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?