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","B","D","F"]

Explanation

A. Store the oxygen cylinder wrench with the oxygen tank.: The wrench is necessary to open the oxygen tank in an emergency or when changing tanks. Keeping it with the tank ensures it is immediately available for the client or caregiver.

B. Take steroid medication in the morning.: Prednisone (a corticosteroid) can cause insomnia and restlessness. Taking it in the morning aligns with the body's natural circadian rhythm of cortisol production and helps prevent sleep disturbances.

C. Decrease the steroid dose each day.: The prescription states "40 mg PO daily for 5 days." The nurse should instruct the client to take the full dose as prescribed. While steroids are often tapered, the client should not self-taper unless specifically directed by the provider's prescription.

D. Take antibiotic medication with or without food.: Cephalexin can be taken without regard to meals. However, if the medication causes GI upset, taking it with food can help mitigate nausea.

E. Adjust the oxygen flow rate as needed to ease breathing.: Oxygen is considered a medication. The client must maintain the prescribed flow rate (3 L/min) and should never adjust it without a provider's order, as excessive oxygen can be harmful to some patients.

F. Ensure the oxygen delivery system is at least 8 feet from any heat source.: Oxygen supports combustion. To prevent fires, tanks and concentrators must be kept away from open flames, space heaters, candles, or gas stoves. Standard safety guidelines usually recommend 5 to 10 feet (8 feet is a safe middle ground).

G. Take antibiotics for 10 days.: The prescription specifically states "every 6 hr for 5 days." Taking medications for longer than prescribed is incorrect instruction.

A. Photo identification B. Room number C. Facility-assigned identification number D. Diagnosis E. Date of birth

Correct Answer is ["A","C","E"]

Explanation

A. Photo identification: In many long-term care settings, a photo is used as a secondary identifier for clients who may be confused or non-verbal.

B. Room number: Room numbers are never used as identifiers because clients can be moved or transferred between rooms.

C. Facility-assigned identification number: This is a unique number assigned to the specific client upon admission.

D. Diagnosis: Multiple clients on a unit may share the same diagnosis (e.g., CHF or Diabetes).

E. Date of birth: This is a standard, unique identifier used in conjunction with the client's name.

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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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Naxlex Comprehensive Predictor Exams

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