A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?
Cause of the client's death
Last set of the client's vital signs
Copy of the client's advance directives
Location of the identification tag on the client's body
The Correct Answer is D
A. Incorrect. The cause of death is an important piece of information but is typically included in the official death certificate rather than in routine postmortem documentation.
B. Incorrect. While vital signs are important during the client's care, the last set of vital signs is not usually a primary focus of postmortem documentation.
C. Incorrect. Advance directives are relevant to the client's care during life but are not typically included in postmortem documentation.
D. Correct. Documentation of the location of the identification tag on the client's body is important for accurate identification and tracking during the postmortem process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choicea. Obtain the client’s blood pressure in the other arm.
Choice A rationale:
Obtaining the client’s blood pressure in the other arm is crucial to avoid compromising the arteriovenous fistula. Measuring blood pressure in the arm with the fistula can damage the access site and impair its function.
Choice B rationale:
Encouraging the client to increase fluid intake is not appropriate for clients undergoing hemodialysis, as they often need to restrict fluid intake to prevent fluid overload.
Choice C rationale:
Reinforcing with the client to sleep on the side of the access site is incorrect. Clients should avoid sleeping on the arm with the fistula to prevent compression and potential damage to the access site.
Choice D rationale:
Obtaining the client’s weight is important for monitoring fluid balance, but it is not specific to the care of the arteriovenous fistula.
Correct Answer is C
Explanation
A. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
B. Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
C. Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D. Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
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