A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

Completion of an incident report.

Name of the nurse certifying the client's death.

Release of personal belongings form.

One client identifier at the client's time of death.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Release of personal belongings form.

Choice A rationale:

Completion of an incident report is not typically part of postmortem care documentation unless there was an unusual or unexpected event surrounding the death.

Choice B rationale:

While the name of the nurse certifying the client’s death is important, it is usually documented separately in the death certificate or other official records, not necessarily in the postmortem care documentation.

Choice C rationale:

The release of personal belongings form is crucial as it ensures that the client’s belongings are properly accounted for and handed over to the appropriate person, providing a clear record of what was released and to whom.

Choice D rationale:

Documenting one client identifier at the time of death is important, but it is not specific to postmortem care documentation. Identifiers are generally used throughout the client’s medical record to ensure accuracy and consistency.

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Correct Answer is B

Explanation

The correct answer is choice B: Empty the drainage bag when it is three-fourths full.

Choice A rationale:

Cleaning the perineal area at least once a day is important for maintaining hygiene, but it is not the most relevant action in this scenario. The focus here is on managing the urinary catheter and its drainage bag.

Choice B rationale:

Emptying the drainage bag when it is three-fourths full is the correct action. An indwelling urinary catheter requires regular drainage to prevent the risk of infection and blockages. Allowing the bag to become too full could lead to backflow and increase the likelihood of urinary tract infections.

Choice C rationale:

Flushing the catheter with sterile water daily is not typically part of routine catheter care. Catheter flushing might be done for specific medical reasons, but it is not a general guideline for indwelling catheters.

Choice D rationale:

Disconnecting the drainage bag when emptying and measuring urine is incorrect. Maintaining a closed system is crucial to prevent introducing bacteria into the urinary tract. Disconnecting the bag could increase the risk of infection.

A. Clean hands with an alcohol-based hand rub immediately after removing gloves. B. Remove the cover gown in the client's room after providing care. C. Place the client in a room with negative-pressure airflow. D. Wear a mask when administering oral medications to the client.

Correct Answer is B

Explanation

The correct answer is choice B. Remove the cover gown in the client’s room after providing care. This is because Clostridium difficile spores are not effectively killed by alcohol-based hand rubs and can survive on surfaces for a long time. Removing the gown in the client’s room helps to contain any spores that may have settled on the gown, preventing them from being spread to other areas.

Choice A rationale:

Cleaning hands with an alcohol-based hand rub immediately after removing gloves is wrong because C. difficile spores are resistant to alcohol-based hand rubs. The recommended practice is thorough handwashing with soap and water to physically remove the spores from the hands.

Choice C rationale:

Placing the client in a room with negative-pressure airflow is wrong because this measure is used for airborne infections, such as tuberculosis. C. difficile is spread via the fecal-oral route, primarily through contact with contaminated surfaces or hands, not through the air.

Choice D rationale:

Wearing a mask when administering oral medications to the client is wrong because C. difficile is not spread through respiratory droplets. Masks are not necessary unless there is a risk of splash or spray of contaminated material.

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A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?

Correct Answer is B

Explanation

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