A nurse is caring for a client who has recently died. Which of the following actions should the nurse take?

Remove the absorbent pads from underneath the client.

Place a pillow under the client's head.

Place the client in high-Fowler's position.

Remove the client's dentures

Answer and Explanation

The Correct Answer is A

The nurse should remove the absorbent pads from underneath the client, place the client in a supine position with arms at the sides, close the client's eyes, and replace the client's dentures.

A pillow may be placed under the client's head for cosmetic purposes, but this is not a necessary action. High-Fowler's position is not appropriate for a deceased client.

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Correct Answer is C

Explanation

A.Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.

B.This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.

C. This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.

D.While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.

A. "My child still wets the bed at least two times per week." B. "I have noticed that my child is withdrawn since we switched day care providers." C. "I have a difficult time getting my child to eat green vegetables." D. "My child continually asks me the same questions."

Correct Answer is B

Explanation

The guardian's observation about the child being withdrawn since the switch of daycare providers is particularly important. It suggests a change in behavior that could potentially indicate emotional or social difficulties.

The nurse should explore this further to gather more information and assess the child's well-being in the new daycare setting. It is essential to ensure the child's emotional health and address any potential issues that may be affecting their well-being and development.

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A nurse is caring for a client who has recently died. Which of the following actions should the nurse take?

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