A nurse is caring client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

A) Position the client’s head toward Mecca: In Islam, it is customary to position the deceased's body with the head facing toward Mecca, the holy city of Islam. This is an important religious practice and should be followed during postmortem care to respect the deceased's cultural and religious beliefs.

B) Allow a family member of the client to stay with the client’s body until burial: It is customary in many Islamic traditions for a family member to stay with the body, providing comfort and ensuring the body is treated with respect. However, the nurse should ensure this is done within the hospital's policies and in a safe, culturally sensitive manner. This practice should be respected, but it is not the immediate priority for the nurse during postmortem care.
C) Allow a family member to stay with the client’s body for 8hr: While some Islamic traditions may involve family members staying with the body, the nurse should adhere to the specific wishes of the family and the institution's policies. The 8-hour duration is not a specific religious requirement, and the focus should be on providing respectful, appropriate care and ensuring the family’s wishes are honored within the hospital's guidelines.

D) Position the client’s head northward: In Islamic traditions, the body is positioned with the head facing toward Mecca, not northward. Positioning the head in a direction other than toward Mecca would not align with the cultural practices of Islam regarding postmortem care. Therefore, this action would not be appropriate.

A) Document the infiltration: While documentation is an important part of the nursing process, it is not the first action to take. If an infiltration is suspected, the priority is to stop the infusion immediately to prevent further harm or fluid leakage into the surrounding tissues. Once the infusion is stopped, the nurse can then document the infiltration for medical record purposes.

B) Elevate the arm: Elevating the arm can help reduce swelling, but this should not be the first step. The first priority when infiltration is suspected is to stop the infusion, as continuing it can worsen the tissue damage and swelling. After stopping the infusion, elevating the arm may be considered as part of the subsequent management of the infiltration.

C) Apply a warm compress: A warm compress may be helpful after stopping the infusion, particularly if the infiltration involves non-vesicant fluids. However, applying a warm compress is not the immediate action. The first step should be stopping the infusion to prevent any further fluid from infiltrating the tissues.

D) Stop the infusion: The most immediate and appropriate action when infiltration is noted around the IV insertion site is to stop the infusion. This prevents additional fluid from leaking into the surrounding tissues, which could cause further damage. Once the infusion is stopped, the nurse can take other steps to manage the infiltration, such as assessing the site, applying a warm compress, or notifying the healthcare provider.