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.

Answer and Explanation

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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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.

A. Supporting the client's wish to refuse prescribed medications B. Explaining unit rules and policies regarding unacceptable behaviors C. Making sure the client understands expectations for client participation D. Encouraging client feedback about satisfaction with the facility experience

Correct Answer is A

Explanation

A. Supporting the client's wish to refuse prescribed medications. Autonomy refers to the right of individuals to make their own decisions regarding their healthcare. If a client chooses to refuse medication, the nurse must respect this decision, as long as the client is deemed competent to make informed choices.
B. Explaining unit rules and policies regarding unacceptable behaviors. This action supports a structured therapeutic environment but does not specifically relate to autonomy. It aligns more with beneficence (acting in the client’s best interest) and justice (ensuring fairness in care).
C. Making sure the client understands expectations for client participation. Ensuring understanding of treatment expectations promotes informed participation but does not directly uphold the ethical principle of autonomy, which emphasizes the right to make personal choices.
D. Encouraging client feedback about satisfaction with the facility experience. Seeking client feedback supports patient-centered care but does not specifically demonstrate autonomy, which involves the right to accept or refuse medical interventions.

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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?

Nursing Test Bank

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