A nurse is performing postmortem care for a client who has just died. Which of the following actions should the nurse take?

Close the client's eyes with paper tape.

Identify the client using two identifiers.

Remove the client's pillow to prevent discoloration of the face.

Remove the client's dentures.

Answer and Explanation

The Correct Answer is B

A. Close the client's eyes with paper tape: The eyes should be gently closed manually or by placing a small rolled gauze over the eyelids; paper tape can irritate the skin or damage fragile tissue and is not recommended.

B. Identify the client using two identifiers: Proper identification using two identifiers, such as name and medical record number, is essential in postmortem care to ensure accurate handling of the body, compliance with legal requirements, and prevention of errors.

C. Remove the client's pillow to prevent discoloration of the face: The pillow may be adjusted for comfort and positioning, but removing it to prevent discoloration is not standard practice. Discoloration due to livor mortis is a natural process and cannot be prevented by pillow placement.

D. Remove the client's dentures: Dentures should remain in place during postmortem care to maintain facial structure and natural appearance for viewing by family. Removal is only necessary if required for identification or specific postmortem procedures.

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Correct Answer is B

Explanation

A. "Place guns in a locked glass cabinet.": A glass cabinet, even if locked, does not provide adequate security because glass can be broken easily. This storage method increases the risk of children or unauthorized individuals accessing the firearm.

B. "Keep ammunition and guns in separate, locked locations.": Storing firearms and ammunition separately and in locked containers minimizes the risk of accidental shootings by ensuring that even if one is accessed, the other remains secured, thereby preventing immediate use.

C. "Remove ammunition from the firearm and place it on a table before cleaning.": Although removing ammunition is necessary before cleaning, leaving it out in the open still poses a risk. Safe practices require storing ammunition in a secure, locked area rather than accessible.

D. "Plan to have the firearm inspected by a gunsmith every 5 years.": While firearm inspections may be useful for maintenance, they do not directly reduce the risk of injury in the home. Safety measures focus more on secure storage and limiting access to firearms and ammunition.

A. "I think you should call your friends to comfort you." B. "Things are not as bad as they seem right now." C. "It must be a very difficult time for you." D. "Why are you afraid that you are going to die?"

Correct Answer is C

Explanation

A. "I think you should call your friends to comfort you.": This deflects the client’s feelings and shifts responsibility to others, rather than addressing the client’s immediate emotional needs.

B. "Things are not as bad as they seem right now.": This minimizes the client’s fear and invalidates their feelings, which can prevent open communication about their concerns.

C. "It must be a very difficult time for you.": This is a therapeutic, empathetic response that acknowledges the client’s emotions and encourages them to share their fears in a supportive manner.

D. "Why are you afraid that you are going to die?": Asking "why" can sound judgmental or probing, which may make the client defensive instead of fostering trust and open discussion.

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