A nurse is performing postmortem care for a recently deceased client prior to the client’s family visit.
Which of the following actions should the nurse plan to take?
Cross the client’s arms across their chest.
Place the client in a high-Fowler’s position
Hold the client’s eyes shut for a few seconds.
Remove the client’s dentures from their mouth
The Correct Answer is C
The correct answer is choice C. Holding the client’s eyes shut for a few seconds.
This is because the eyes of a deceased client do not close naturally and may remain open after death. Holding them shut for a few seconds helps to keep them closed and prevent drying of the corneas.
This also gives a more peaceful appearance to the client’s body for the family visit.
Choice A is wrong because crossing the client’s arms across their chest is not a standard postmortem care procedure. It may also interfere with the placement of identification tags on the wrists.
Choice B is wrong because placing the client in a high-Fowler’s position is not necessary or appropriate for postmortem care. The client should be placed in a supine position with the head of the bed elevated to prevent livor mortis (purple discoloration of the skin) on the face.
Choice D is wrong because removing the client’s dentures from their mouth is not recommended for postmortem care. The dentures should be left in place to maintain the shape of the face and prevent the jaw from dropping.
Normal ranges are not applicable for this question as it does not involve any physiological measurements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. The nurse should choose a vein that is palpable and straight for IV catheter insertion.
This will facilitate the insertion of the catheter and reduce the risk of complications such as infiltration, phlebitis, or hematoma. A straight vein will also allow the catheter to be inserted up to the hub, which reduces the risk of contamination along the length of the catheter.
Choice A is wrong because selecting a site on the client’s dominant arm can interfere with the client’s mobility and increase the risk of dislodging the catheter. The nurse should choose a site on the client’s non-dominant arm, preferably on the hand or forearm.
Choice B is wrong because applying a tourniquet below the venipuncture site will impede blood flow and make it harder to locate a suitable vein. The nurse should apply a tourniquet above the venipuncture site, about 10 to 15 cm from the insertion site.
Choice C is wrong because elevating the client’s arm prior to insertion will decrease venous filling and make it harder to palpate a vein. The nurse should lower the client’s arm below the level of the heart to increase venous distension.
Normal ranges for IV catheter size and insertion angle depend on several factors, such as the type and duration of therapy, the condition and size of the vein, and the age and preference of the client.
In general, smaller gauge catheters (20 to 24) are preferred for peripheral IV therapy, and larger gauge catheters (14 to 18) are used for rapid fluid administration or blood transfusion. The insertion angle can vary from 10 to 30 degrees, depending on the depth and location of the vein.
Correct Answer is D
Explanation
Answer and explanation.
The correct answer is choice D. Herpes zoster is a contraindication for receiving acupuncture treatment because it is an infectious skin disorder that can be transmitted by needles or contact with the affected area. Acupuncture should not be performed on areas of skin that are inflamed, ulcerated, or have sensory deficit.
Choice A is wrong because hypertension is not a contraindication for acupuncture. However, some caution is advised when needling points that may lower blood pressure, such as LI 4, LI 11, ST 36, and SP 6.
Choice B is wrong because hypothyroidism is not a contraindication for acupuncture. In fact, some studies suggest that acupuncture may have beneficial effects on thyroid function and symptoms of hypothyroidism.
Choice C is wrong because obesity is not a contraindication for acupuncture.
Acupuncture may help with weight loss by regulating appetite, metabolism, and hormones.
Some of the absolute contraindications for acupuncture include pregnancy (especially certain points that may induce labor or abortion), medical and surgical emergencies, malignant tumors, bleeding disorders, and use of a demand pacemaker. Some of the relative contraindications include drug or alcohol intoxication, lack of consent, immune deficiency, abnormal heart valves, and fear of needles.
Normal ranges for blood pressure are 120/80 mmHg or lower for systolic and diastolic pressure respectively.
Normal ranges for thyroid-stimulating hormone (TSH) are 0.4 to 4.0 mIU/L.
Normal ranges for body mass index (BMI) are 18.5 to 24.9 kg/m2.
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