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A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?

Washing the client's face

Gathering the client's personal belongings

Closing the client's eyes

Removing the client's dentures from their mouth

Answer and Explanation

The Correct Answer is D

Rationale:

A. Washing the client's face is part of postmortem care and is appropriate.

B. Gathering the client's personal belongings is part of postmortem care and is appropriate.

C. Closing the client's eyes is part of postmortem care and is appropriate.

D. Removing the client's dentures from their mouth is not part of postmortem care and may be distressing for the family. The nurse should intervene and ensure the dentures are left in place.

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Correct Answer is B

Explanation

Rationale:

A. Drinking an average of 2,000 milliliters of water daily is a healthy habit that promotes bowel elimination.

B. Taking a prescribed opioid pain medication at bedtime can cause constipation and impaired bowel elimination.

C. Eating apples and black-eyed peas is a healthy dietary choice that promotes bowel elimination.

D. Drinking two hot cups of coffee each morning can promote bowel elimination for some individuals.

A. Unlock and remove the inner cannula. B. Scrub the inside and outside of the inner cannula with a small brush C. Wipe the inside of the inner cannula with a folded pipe cleaner. D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. E. Cleanse the stoma site with 0.9% sodium chloride solution.

Correct Answer is A,D,B,C,E

Explanation

A. Unlock and remove the inner cannula is the first step because it allows access to the inner cannula for cleaning.
B. Scrub the inside and outside of the inner cannula with a small brush is the third step because it removes debris and secretions from the inner cannula.
C. Wipe the inside of the inner cannula with a folded pipe cleaner is the fourth step because it further cleans the inner cannula.
D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin is the second step because it provides the solution for cleaning the inner cannula.

E. Cleanse the stoma site with 0.9% sodium chloride solution is the final step because it cleans the stoma site before replacing the inner cannula.

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A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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