A nurse is preparing a client's body for a postmortem family viewing.
Which of the following actions should the nurse take?
Ask the family if they want to participate in postmortem care.
Lie the head of the client's bed flat.
Place medical equipment to the side of the client's bed.
Remove the client's dentures to close their mouth.
The Correct Answer is A
Choice A- Ask the family if they want to participate in postmortem care Asking the family if they want to participate in post-mortem care is an important step to involve them in the process and respect their wishes. Some families may prefer to have healthcare professionals handle the post-mortem care, while others may want to participate in certain aspects. It is crucial to communicate and collaborate with the family to ensure their preferences are respected. Choice B- Lie the head of the client's bed flat. This response is not appropriate. Elevate the head of the bed as soon as possible after death to prevent discoloration of the face. Choice C- Place medical equipment to the side of the client's bed. Is not directly related to the preparation for a post-mortem family viewing. However, it is important to ensure a respectful and organized environment during the viewing, so any unnecessary medical equipment or supplies should be removed from the immediate vicinity of the client's bed. Choice D-Remove the client's dentures to close their mouth. Leave dentures in the mouth to maintain facial shape.The mouth can be gently closed without removing dentures, unless there are specific cultural or family preferences regarding the dentures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can be a side effect of enalapril and may lead to syncope. Instructing the client to rise slowly from a sitting to a standing position helps minimize the risk of a sudden drop in blood pressure and decreases the chances of syncope occurring.
Decreasing fluid intake is not likely to be the cause of syncope related to enalapril. It is important for clients to maintain adequate hydration, especially if they are experiencing side effects such as orthostatic hypotension.
While a low pulse rate may indicate bradycardia, it is not the primary concern in this situation. Orthostatic hypotension leading to syncope is the main issue, and the client should be instructed to rise slowly to prevent it.
While enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can increase potassium levels in the blood, it is not directly related to syncope. Dietary changes should be made under the guidance of a healthcare provider based on individual needs and blood test results.
Correct Answer is D
Explanation
Diminished pulses in the affected extremity can indicate compromised circulation, which is a serious concern. It could suggest the development of compartment syndrome, a condition characterized by increased pressure within the muscles and tissues of the leg. Compartment syndrome can lead to tissue damage and potentially jeopardize the client's limb. Therefore, it is crucial for the nurse to recognize and address this finding promptly.
One fingerbreadth of space between the cast and the skin is generally considered an appropriate amount of space to allow for swelling and adequate circulation. However, it should still be monitored for any changes or signs of compartment syndrome.
Ecchymosis on the inner left thigh may indicate bruising, which could be related to the injury or the application of the cast. While it should be documented and monitored, it does not pose an immediate threat to the client's well-being.
The client reported that muscle spasms of the left leg can be a common occurrence due to muscle immobility and discomfort associated with the cast. Although it should be assessed and managed for the client's comfort, it is not as urgent as addressing compromised circulation.
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