A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

Ask the assist personnel to document the client's time of death.

Place an identification tag on the outside of the client's shroud.

Wear sterile gloves when cleaning the client's body.

Remove the client's dentures and give them to the client's family.

Answer and Explanation

The Correct Answer is B

A. Asking the assist personnel to document the client's time of death is not correct. While accurate documentation of the time of death is important, the responsibility typically falls on the healthcare provider or physician who confirms the death, not necessarily the assist personnel involved in postmortem care. B. Place an identification tag on the outside of the client's shroud is correct. This action ensures proper identification throughout the postmortem process and aligns with standard procedures for maintaining identification integrity during autopsy procedures. Identifying the client accurately is crucial to prevent any errors or mix-ups. C. Wearing sterile gloves when cleaning the client's body is incorrect. Sterile gloves are not typically required for postmortem care. While gloves are important for infection control, they don't necessarily need to be sterile for handling deceased patients unless there are specific infectious concerns. D. Removing the client's dentures and give them to the client's family is incorrect. In most cases, the client's personal belongings, including dentures, are typically handled according to specific protocols or the family's wishes. However, removing the dentures and giving them to the family isn't typically part of postmortem care. The family might be informed about the presence of dentures and their disposition, but the decision to give them to the family should follow established procedures or the family's preferences.

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Correct Answer is C

Explanation

Choice A Reason:

Have the client sign an against medical advice (AMA) form is incorrect. While this form allows patients to leave against medical advice after acknowledging the risks, it should be used after thorough discussion, ensuring the patient understands the consequences. In this case, the client is postoperative and might not have received clearance from the surgeon, so this option may not be appropriate without further assessment.

Choice B Reason:

Tell the client that the surgeon will prescribe restraints if they try to leave is incorrect. Threatening restraints is not a suitable or ethical approach. Using restraints should be a last resort for ensuring safety, especially if a patient is attempting to leave. It's crucial to communicate and engage in dialogue rather than resorting to threats or coercion.

Choice C Reason:

Explain to the client that they cannot leave until the surgeon discharges them is correct. This action prioritizes the safety and well-being of the client while also informing them of the necessary procedure before leaving the hospital. It's essential to communicate the discharge process and ensure that the client understands the potential risks of leaving without proper medical approval. This approach maintains respect for the client's autonomy while emphasizing the importance of following the medical protocol for a safe recovery.

Choice D Reason:

Administer a sedative medication to the client is incorrect. Using sedatives to prevent a patient from leaving is not ethically or medically appropriate unless there's a critical situation where the patient is a danger to themselves or others. Administering sedatives without proper justification or consent violates ethical principles and could potentially harm the patient.

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

Correct Answer is ["A","B","C","D","E"]

Explanation

1. Unlock and remove the inner cannula (Step C). This is the initial step because it allows access to the inner cannula for cleaning. Removing it enables further cleaning of the inner cannula and ensures proper hygiene of the tracheostomy.

2. Scrub the inside and outside of the inner cannula with a small brush (Step D). Once the inner cannula is removed, it should be cleaned thoroughly to remove any secretions or debris. Scrubbing with a small brush helps in effectively cleaning both the inside and outside surfaces.

3. Wipe the inside of the inner cannula with a folded pipe cleaner (Step E). Using a pipe cleaner helps to reach areas that a brush might not access easily. It further ensures the removal of any remaining secretions or buildup inside the inner cannula.

4. Cleanse the stoma site with 0.9% sodium chloride solution (Step B). After addressing the inner cannula, the nurse moves to clean the stoma site to prevent infection or irritation. This step ensures the area around the tracheostomy is clean and free from contaminants.

5.Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin (Step A). Lastly, preparing the sterile basin with the saline solution should be done at the start to ensure it's ready for use during the cleaning process. This solution will be utilized for cleaning the stoma site in step B and may also be needed for moistening the brush or pipe cleaner during steps D and E.

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A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

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Correct Answer is C

Explanation

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Correct Answer is ["A","B","C","D","E"]

Explanation

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