A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

Location of the identification tag on the client's body

Cause of the client's death

Last set of the client's vital signs

Copy of the client's advance directives

Answer and Explanation

The Correct Answer is A

a. Location of the identification tag on the client's body: This is essential information that should be included in the documentation. It ensures that the deceased person is properly identified and helps prevent any mix-ups during subsequent processes, such as transferring the body to the morgue or a funeral home.

b-While this information is important, it's typically documented by the physician on the death certificate and is not generally part of the nurse's postmortem documentation.

c-The last set of vital signs is not usually required for postmortem documentation. Postmortem documentation focuses on the condition of the body and identification rather than the final vital signs, which are often irrelevant after death.

d-Advance directives should be reviewed before death and guide the care provided, but they are not part of postmortem documentation. A copy of the client's advance directives may also be included in their medical record but is not typically included in postmortem documentation.

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Correct Answer is D

Explanation

Hyperactive bowel sounds refer to an increased intensity, frequency, and loudness of bowel sounds. They are typically described as loud, high-pitched, and occurring more frequently than normal. This can indicate increased bowel motility and may be associated with conditions such as diarrhea, gastroenteritis, or bowel obstruction.

No sounds heard after listening for 3 to 5 minutes: This describes absent or hypoactive bowel sounds, where no sounds or very few sounds are heard. It can indicate decreased or absent bowel motility and may be seen in conditions such as ileus or peritonitis.

Sounds are soft and at a rate of 1/min: This describes normal or hypoactive bowel sounds, where the sounds are relatively quiet and occur at a slower rate (usually 5-34 sounds per minute). It may be observed in situations such as during sleep, after eating, or in certain conditions like constipation or paralytic ileus.

Indicates decreased motility: This is an inaccurate statement for hyperactive bowel sounds.

Hyperactive bowel sounds actually indicate increased motility, as mentioned earlier. Decreased motility would be associated with hypoactive or absent bowel sounds.

A. Clean the stoma using an inward-to-outward circular motion. B. Cleanse the inner cannula with isopropyl alcohol. C. Ensure at least three finger widths of space under tracheostomy ties. D. Prepare sterile supplies after removing the inner cannula.

Correct Answer is A

Explanation

The correct answer is: a. Clean the stoma using an inward to outward circular motion.

Title: Choice A reason: Cleaning the stoma with an inward to outward circular motion is a recommended practice to prevent infection and ensure that any debris or secretions are cleared away from the tracheostomy site. This method helps to minimize the risk of introducing pathogens directly into the stoma and is considered a best practice in tracheostomy care.

Title: Choice B reason: Cleansing the inner cannula with isopropyl alcohol is not recommended because it can cause irritation to the tracheal mucosa. Instead, sterile saline is typically used for cleaning the inner cannula to avoid any potential damage to the tracheal tissues and to maintain a safe and comfortable environment for the patient.

Title: Choice C reason: Ensuring at least three finger widths of space under tracheostomy ties is not the standard practice. The recommended space is to allow one to two finger widths under the tracheostomy ties to ensure they are secure but not too tight, which could lead to skin breakdown or discomfort for the patient.

Title: Choice D reason: Preparing sterile supplies should be done before removing the inner cannula, not after. This is to ensure that all necessary supplies are ready to use immediately after the inner cannula is removed, minimizing the time the stoma is open and reducing the risk of infection.

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A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

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