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: A client who has measles.

Choice A rationale:

Airborne precautions are indicated for diseases that spread via small particles suspended in the air, such as droplets or dust particles that remain in the air for prolonged periods. Pneumonia is primarily spread through larger respiratory droplets and is not considered an airborne disease. Therefore, airborne precautions are not necessary for a client with pneumonia.

Choice B rationale:

Measles is a highly contagious airborne disease caused by the measles virus. It is transmitted through respiratory droplets and can remain in the air for an extended period. Initiating airborne precautions, such as wearing an N95 respirator mask and placing the client in a negative pressure isolation room, is crucial to prevent the spread of measles to healthcare workers and other patients.

Choice C rationale:

Pertussis (whooping cough) is primarily spread through respiratory droplets, similar to pneumonia. While it is a serious bacterial infection, it is not classified as an airborne disease. Thus, airborne precautions are not required for a client with pertussis.

Choice D rationale:

Methicillin-resistant Staphylococcus aureus (MRSA) is mainly spread through direct contact with contaminated surfaces or individuals. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air. Standard precautions, including wearing gloves and gowns, are typically sufficient when caring for a client with MRSA.

A. "What types of foods have you been eating?” B. "Are you using stool softeners or laxatives?” C. "Have you been passing gas?” D. "Have you had small liquid stools?”

Correct Answer is D

Explanation

The correct answer is choice d. “Have you had small liquid stools?”

Choice A rationale:

While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.

Choice B rationale:

Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.

Choice C rationale:

Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.

Choice D rationale:

Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.

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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?

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