A nurse is caring for a client who just died. The client's family requests to perform the postmortem care. Which of the following responses should the nurse make?

"You will have to sign a release form to perform the care yourself."

"I will assist you in any way I can during this process."

"This care takes place after the client leaves the facility."

"A licensed health care worker must perform postmortem care."

Answer and Explanation

The Correct Answer is B

A. "You will have to sign a release form to perform the care yourself.": There is no standard legal release form required for family involvement in postmortem hygiene.

B. "I will assist you in any way I can during this process.": This is a culturally sensitive and therapeutic response. Allowing the family to participate in postmortem care can provide closure and honor religious or personal rituals.

C. "This care takes place after the client leaves the facility.": Postmortem care is performed immediately after death in the facility to prepare the body for the family to view and for transport.

D. "A licensed health care worker must perform postmortem care.": While the nurse is responsible for the overall process, there is no law preventing family members from assisting or performing the care themselves if they wish.

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Correct Answer is A

Explanation

A. The stoma appears dark in color.: A healthy stoma should be moist and reddish-pink. A dark (purple, black, or dusky) stoma indicates ischemia or poor perfusion and must be reported immediately to prevent tissue death.

B. The stoma bleeds lightly when touched.: This is a common and expected finding, as stoma tissue is highly vascular and fragile, especially in the early postoperative period.

C. The stoma is draining a small amount of liquid stool.: This is an expected finding 2 days postoperatively as the bowel begins to resume function.

D. The stoma protrudes slightly from the abdomen.: A slight protrusion (budding) is normal and helps the stool fall into the collection pouch rather than sitting on the skin.

A. The client holds the cane on the stronger side of their body. B. The top of the cane is at the same height as the client's waist. C. The client moves their stronger leg forward first. D. The client advances the cane forward 12.7 cm (5 in).

Correct Answer is A

Explanation

A. The client holds the cane on the stronger side of their body.: Holding the cane on the unaffected (stronger) side provides a wider base of support and shifts weight away from the weaker leg.

B. The top of the cane is at the same height as the client's waist.: The top of the cane should reach the level of the greater trochanter or the wrist crease.

C. The client moves their stronger leg forward first.: The cane and the weaker leg should move forward together first, followed by the stronger leg.

D. The client advances the cane forward 12.7 cm (5 in).: Standard instruction is to advance the cane 15 to 25 cm (6 to 10 inches) to maintain stability.

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A nurse is caring for a client who just died. The client's family requests to perform the postmortem care. Which of the following responses should the nurse make?

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