A nurse is assisting in the care of a 72-year-old female client who recently had a stroke and is being monitored for complications.

Exhibits

Complete the following sentence by using the lists of options. The client is at risk for developing

dropdown

due to

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.

Choice A rationale

Placing an identification tag on the outside of the client's shroud is essential for proper identification, especially in cases requiring an autopsy. This practice ensures that the deceased person is accurately identified throughout the process and helps prevent any mix-ups or misidentifications.

Choice B rationale

Asking the assistive personnel to document the client's time of death is incorrect as it is the nurse's responsibility to document the time of death accurately in the medical records, not the assistive personnel's duty.

Choice C rationale

Wearing sterile gloves when cleaning the client's body is not necessary. Standard precautions and the use of non-sterile gloves are sufficient for postmortem care unless there are specific reasons requiring sterility, which is uncommon.

Choice D rationale

Removing the client's dentures and giving them to the client's family is incorrect for an autopsy case. Dentures should be left in place to maintain the integrity of the body and to ensure that all personal effects are accurately documented and managed.

Choice A rationale

Flexing hips and knees when assisting the client to a standing position uses proper body mechanics, reducing the risk of injury to both the nurse and the client. It provides a stable base of support during the transfer.

Choice B rationale

Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect. The nurse should pivot on the foot closest to the bed to maintain balance and control during the transfer.

Choice C rationale

Standing on the client's stronger side when moving the client into the chair is incorrect. The nurse should stand on the client's weaker side to provide support and prevent falls.

Choice D rationale

Raising the bed to waist level before moving the client is incorrect as it may not provide the best ergonomic position for the transfer. The bed should be at a height that ensures the nurse’s safety and facilitates the client's movement.