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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A fever may influence the result of an oxygen saturation test but is not a direct factor.
B. An elevated hemoglobin level is unlikely to influence the result of an oxygen saturation test.
C. Wearing a ring is unlikely to influence the result of an oxygen saturation test.
D. Wearing nail polish can interfere with the accuracy of pulse oximetry readings by causing an inaccurate reflection of light, leading to a falsely low oxygen saturation reading.
Correct Answer is B
Explanation
Rationale for A: Providing oral care once every 8 hours is not directly related to relieving dyspnea. Oral care addresses comfort related to dry mouth, but it doesn't improve breathing difficulties.
Rationale for B: Repositioning the client every 4 hours can help alleviate dyspnea by improving lung expansion and preventing pooling of secretions. It also helps in reducing pressure injuries, promoting comfort, and preventing complications.
Rationale for C: Placing the head of the bed flat can exacerbate dyspnea by hindering lung expansion. It is recommended to elevate the head of the bed to improve air exchange and breathing.
Rationale for D: While using a fan can help with the sensation of breathlessness, repositioning every 4 hours is a more direct action to support ventilation and reduce dyspnea.
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