A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select All that Apply.)

Remove the dentures from the body.

Dim the lights in the room.

Remove all equipment from the bedside.

Apply fresh linens and place a clean gown on the body.

Make sure the body is lying completely flat.

Answer and Explanation

Correct Answer : B,C,D

A. Remove the dentures from the body: Dentures should typically be left in place unless otherwise directed, as removing them can alter the appearance of the deceased and may be distressing for the family.
B. Dim the lights in the room: Dimming the lights can create a more respectful and soothing environment for the family during their time of mourning.
C. Remove all equipment from the bedside: Removing equipment ensures a clear and respectful presentation of the body, allowing the family to view their loved one without distractions.
D. Apply fresh linens and place a clean gown on the body: This action helps present the body in a respectful manner, making it more presentable for the family.
E. Make sure the body is lying completely flat: The body should be positioned appropriately based on the clinical setting and family preferences, but the focus should be on creating a respectful and dignified presentation rather than strictly ensuring the body is completely flat.

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Correct Answer is B

Explanation

A. Droplet: Incorrect. Droplet precautions are used for infections spread through respiratory droplets, such as influenza or meningitis, not for immunocompromised clients undergoing stem-cell transplants.
B. Protective: Correct. Protective precautions, also known as neutropenic precautions or reverse isolation, are necessary for clients who are immunocompromised, such as those who have had a stem-cell transplant. These precautions include using barrier protection to prevent infection due to the client's weakened immune system.
C. Contact: Incorrect. Contact precautions are used for infections spread by direct or indirect contact with contaminated surfaces or items, such as Clostridium difficile, not for immunocompromised patients.
D. Airborne: Incorrect. Airborne precautions are used for infections that spread through the air over long distances, such as tuberculosis or measles, and are not specifically needed for clients with compromised immunity post-transplant.

A. 12/18/200XX 0915 Morphine 2 mg IV for incisional pain. TOJ Winds. RN, read back B. 12/16/2000x 0915 Morphine. 2 mg IV every 4 hours for incisional pain TOJ Winds, RN C. 12/16/20XX 0915 Morphine, 2 mg IV every 4 hours for incisional pain. TO Dr. Day Winds, RN, read back D. 12/16/2000x 0915 Morphine, 2 mg IV every 4 hours for incisional pain. VO Dr. Day Winds, RN, read back.

Correct Answer is C

Explanation

A: This option is incorrect because the date is wrong, and it uses "TOJ" which is not a standard abbreviation in medical documentation. The correct format should include the date the order was received, the medication and dosage, frequency, reason for administration, and the initials of the person taking the order along with a 'read back' confirmation.
B: This choice is incorrect because it lacks the 'read back' confirmation which is a critical part of telephone orders to ensure accuracy. Additionally, the use of "TOJ" is incorrect, and the date format is inconsistent with standard medical records.
C: This is the correct choice because it includes all necessary information: the correct date, medication and dosage, frequency, reason for administration, and it correctly identifies the order as a telephone order with "TO" followed by the doctor's name, and includes the nurse's initials with a 'read back' confirmation.
D: This option is incorrect because it uses "VO" which stands for verbal order, not a telephone order. It also lacks the full date and has an inconsistent date format. The 'read back' confirmation is present, but the incorrect order type makes this entry invalid.

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A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select All that Apply.)

Nursing Test Bank

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