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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Palliative care is an approach to care that focuses on improving the quality of life for individuals with serious or life-threatening illnesses. It aims to provide relief from pain, symptoms, and stress, rather than focusing solely on curing the underlying disease. Palliative care can be provided alongside curative treatments and is not limited to clients with a specific life expectancy.
It does not involve the restriction of nutritional support but rather aims to address the overall physical, emotional, and spiritual needs of the client.
While palliative care may be provided to clients with terminal illnesses, it is not exclusive to them, as it can be initiated at any stage of a serious illness.
Correct Answer is A
Explanation
The correct answer is: a. Temperature 38.8° C (101.8° F)
Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.
Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.
Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.
Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.
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