A nurse is assisting with the postmortem care of a client whose partner is at the bedside. Which of the following actions should the nurse take?
Direct the partner to leave and return once postmortem care is complete.
Instruct the partner not to touch the client’s body.
Place the client’s personal belongings in a safe location in the facility.
Ask the partner about any rituals they would like to be performed.
The Correct Answer is D
Choice A reason: Directing the partner to leave and return once postmortem care is complete is not respectful of the partner's feelings and wishes. The nurse should allow the partner to stay and participate in the postmortem care if they desire.
Choice B reason: Instructing the partner not to touch the client’s body is not compassionate or supportive of the partner's grief. The nurse should encourage the partner to touch, hold, or kiss the client’s body as a way of saying goodbye.
Choice C reason: Placing the client’s personal belongings in a safe location in the facility is a necessary action, but not the priority. The nurse should first ask the partner if they want to keep any of the belongings or give them to the nurse for safekeeping.
Choice D reason: Asking the partner about any rituals they would like to be performed is the most appropriate action. The nurse should respect and facilitate the partner's cultural, religious, or personal preferences for postmortem care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Showing the client a video demonstration of peak flow meter use is a helpful teaching strategy, but it is not the first action that the nurse should take. The nurse should first assess the client's baseline knowledge and readiness to learn before providing any information or instruction.
Choice B reason: Observing the client using the peak flow meter is a way to evaluate the client's learning and skill, but it is not the first action that the nurse should take. The nurse should first determine the client's knowledge of the use of the peak flow meter and then teach the client how to use it correctly.
Choice C reason: Emphasizing the importance of the daily use of the peak flow meter is a way to motivate the client to adhere to the treatment plan, but it is not the first action that the nurse should take. The nurse should first assess the client's knowledge of the use of the peak flow meter and then explain the benefits and rationale of using it regularly.
Choice D reason: Determining the client's knowledge of the use of the peak flow meter is the first action that the nurse should take, as it follows the principle of the nursing process. The nurse should start with assessment, then proceed with planning, implementation, and evaluation. By assessing the client's knowledge, the nurse can identify the client's learning needs, gaps, and preferences, and tailor the teaching accordingly.
Correct Answer is B
Explanation
Choice A reason: Client instructed on self-care needs is not a specific or accurate documentation. The nurse should include the details of the instruction, such as the topics covered, the teaching methods used, the client's response, and the evaluation of learning.
Choice B reason: Oral temperature elevated at 0800 is a specific and accurate documentation. The nurse should include the vital signs and any abnormal findings, such as fever, in the client's health record. The nurse should also report the elevation to the provider and monitor the client for signs of infection.
Choice C reason: Episiotomy approximated, 3 cm (1.18 in) in length is not a specific or accurate documentation. The nurse should include the type, location, and degree of the episiotomy, as well as the condition of the wound, the presence of edema, erythema, or drainage, and the interventions performed.
Choice D reason: Client drank adequate amounts of fluid with meals is not a specific or accurate documentation. The nurse should include the exact amount and type of fluid intake, as well as the output, in the client's health record. The nurse should also assess the client for signs of dehydration or fluid overload.
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