A nurse is caring for a client who has just died following unsuccessful CPR. The family wishes to view the body. Which of the following actions should the nurse take before inviting the family into the room?
Leave resuscitation equipment and supplies at the bedside.
Hold the client's eyelids closed until they remain shut.
Apply identification tags to the client's extremities.
Keep the head of the bed flat.
The Correct Answer is B
A. Leave resuscitation equipment and supplies at the bedside: This can be distressing for the family. Removing such equipment before the family views the body promotes a more peaceful environment.
B. Hold the client's eyelids closed until they remain shut: This is part of postmortem care to maintain a natural appearance. It shows respect and helps prepare the body before the family views it.
C. Apply identification tags to the client's extremities: While necessary, identification tagging is not a priority before the family views the body. It is typically done before transport to the morgue.
D. Keep the head of the bed flat: Elevating the head of the bed slightly helps prevent discoloration due to blood pooling and gives the body a more natural appearance. Keeping it flat is not ideal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Muscle flaccidity: Hypocalcemia typically causes muscle twitching or spasms, not flaccidity. Muscle flaccidity is more often associated with conditions like hyperkalemia or electrolyte imbalances affecting muscle tone in different ways.
B. Lethargy: Lethargy can occur in various conditions, but it is not a hallmark of hypocalcemia. Instead, hypocalcemia usually causes symptoms like irritability, confusion, and muscle cramps rather than general lethargy.
C. Constipation: Constipation is more commonly associated with hypercalcemia, not hypocalcemia. Low calcium levels tend to cause neuromuscular and cardiac symptoms rather than gastrointestinal issues like constipation.
D. Positive Chvostek's sign: A positive Chvostek's sign, which is a twitching of the facial muscles when tapping the facial nerve, is a classic sign of hypocalcemia. It indicates increased neuromuscular excitability, which is characteristic of low calcium levels.
Correct Answer is A
Explanation
A. Use a standardized approach to giving the handoff report: Using a standardized approach, such as SBAR (Situation, Background, Assessment, Recommendation), ensures that all necessary information is communicated clearly and systematically.
B. Encourage the oncoming shift nurse to contact the provider with any questions: The primary focus of the handoff report should be to provide the oncoming nurse with all necessary information. Directly contacting the provider should not be a primary strategy.
C. Provide the handoff report at the nurses' station: Providing a report at the nurses' station may not be private or conducive to clear communication. It is better to conduct the report in a private area or at the client’s bedside to ensure confidentiality and clarity.
D. Record a verbal report on a recorder for the oncoming nurse to listen to: Recorded reports are not ideal for ensuring continuity of care because they lack the interactive aspect of handoff, such as clarifying questions or addressing concerns in real time.
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