A nurse is caring for a terminally ill client on hospice who passed away during the shift. Select the "3" postmortem care actions the nurse should take?
Lay the client's head flat.
Consider any cultural, religious, or social practices of the client that would impact postmortem care.
Dim the lights and minimize noise to provide a calm environment.
Verify the provider has certified and documented death of the client.
Tell the family to leave the room while you prepare the body.
Correct Answer : B,C,D
A. Lay the client's head flat. Keeping the client’s head slightly elevated, rather than flat, helps prevent discoloration from blood pooling in the face. Positioning the body appropriately is part of postmortem care, but laying the head completely flat is not recommended.
B. Consider any cultural, religious, or social practices of the client that would impact postmortem care. Respecting cultural and religious practices is essential in providing compassionate end-of-life care. Some cultures have specific rituals or beliefs regarding handling the body, and the nurse should accommodate these whenever possible.
C. Dim the lights and minimize noise to provide a calm environment. Creating a peaceful environment is important for both the family and staff. A calm, quiet setting allows the family to grieve and say their final goodbyes in a respectful and dignified manner.
D. Verify the provider has certified and documented death of the client. Before proceeding with postmortem care, the nurse must ensure the provider has officially confirmed and documented the time of death. This is a legal requirement and a crucial step in the process.
E. Tell the family to leave the room while you prepare the body. Forcing the family to leave is inappropriate and insensitive. Many families want to be present during postmortem care or take part in rituals. The nurse should offer them the option to stay or leave based on their preference.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Mrs. Thompson is at high risk for developing pressure sores evidenced by the client's end-of-life stage and deteriorating condition.
Emotional distress. While emotional distress is common in end-of-life patients, Mrs. Thompson has already expressed her wishes for a peaceful, pain-free death and has family support for decision-making. Emotional distress is not the primary risk factor for physical complications such as pressure sores.
Dehydration. Decreased oral intake is expected in the end-of-life stage, but dehydration does not directly cause pressure sores. While maintaining comfort is important, forced hydration is often avoided as it may not improve the patient’s quality of life.
Pressure sores. Mrs. Thompson’s declining condition and decreased mobility put her at high risk for developing pressure sores. Limited movement reduces circulation to pressure points such as the heels and sacrum, leading to tissue breakdown. Preventive measures such as repositioning and skin care should be prioritized.
Frequent movement and activity. This is incorrect because frequent movement reduces the risk of pressure sores by promoting circulation and relieving pressure on bony areas. Mrs. Thompson's deteriorating condition likely limits her mobility, making this choice inappropriate.
Ability to communicate their needs. This is incorrect because even if a patient can verbalize discomfort, they may still be unable to move independently. Pressure sores develop primarily due to immobility rather than communication barriers.
End-of-life stage and deteriorating condition. This is correct because patients nearing the end of life experience profound weakness, reduced circulation, and prolonged immobility, all of which increase the risk of pressure sores. These factors make skin breakdown prevention a key nursing priority.
Correct Answer is C
Explanation
A. "This service provides my caregiver the opportunity to take time for themselves." While respite care offers temporary relief for caregivers, palliative care focuses primarily on symptom management and improving the quality of life for individuals with serious illnesses.
B. "I will need to go to a skilled facility to receive these services." Palliative care can be provided in various settings, including hospitals, outpatient clinics, nursing homes, and even the client’s home. It does not require admission to a skilled nursing facility.
C. "This service assists with making me comfortable during my illness." Palliative care aims to improve comfort by managing pain, symptoms, and emotional distress for individuals with chronic or terminal illnesses. It focuses on enhancing quality of life rather than curing the disease.
D. "I will receive help with managing my meals with this service." While palliative care teams may offer nutritional support as part of symptom management, their primary role is to address pain, dyspnea, nausea, and emotional distress rather than meal planning.
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