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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: This is not the correct answer because the FLACC scale is designed for infants and children who are unable to verbalize their pain, not for adults who speak a different language.

Choice B reason: This is not the correct answer because asking an assistive personnel to interpret is not a reliable or ethical way of communicating with the client. The nurse should use a professional interpreter or a certified bilingual staff member.

Choice C reason: This is the correct answer because a communication board is a simple and effective way of assessing the client's pain level and location.

Choice D reason: This is not the correct answer because the FACES pain scale is based on facial expressions that may vary across cultures and languages. The client may not understand or relate to the pictures on the scale.

A. Inject air into the ampule prior to drawing the medication into a syringe. B. Cleanse the tip of the ampule with an alcohol swab after opening. C. Use a filter needle to aspirate the medication. D. Add 0.5 mL of diluent to the medication.

Correct Answer is C

Explanation

Choice A reason: This is incorrect because injecting air into the ampule is not necessary and may cause the medication to spill or spray.

Choice B reason: This is incorrect because cleansing the tip of the ampule with an alcohol swab after opening is not effective and may contaminate the medication.

Choice C reason: This is correct because using a filter needle to aspirate the medication prevents glass particles from entering the syringe and the client.

Choice D reason: This is incorrect because adding diluent to the medication may alter its concentration and potency, and should only be done if instructed by the manufacturer or the prescriber.

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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?

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