A nurse is preparing a client's body for a postmortem family viewing.
Which of the following actions should the nurse take?

Remove the client's dentures to close their mouth.

Place medical equipment to the side of the client's bed.

Lie on the head of the client's bed flat.

Ask the family if they want to participate in postmortem care.

Answer and Explanation

The Correct Answer is D

Answer is d. Ask the family if they want to participate in postmortem care.

a. Remove the client's dentures to close their mouth: This option is incorrect because removing the client's dentures may not be necessary and can alter the client's appearance, causing unnecessary distress to the family during the viewing. Dentures should generally be left in place to maintain the natural shape of the client's face and preserve their appearance as closely as possible. However, if the family expresses a preference for removing the dentures or if it is medically necessary, the nurse should discuss this option with them and follow facility protocols accordingly.

b. Place medical equipment to the side of the client's bed: While it is essential to create a serene and comfortable environment for the family during the viewing, simply placing medical equipment to the side of the client's bed may not be sufficient. Medical equipment should be removed from the room entirely to minimize distractions and create a more peaceful atmosphere for the family. This ensures that the focus remains on the client and their loved ones during this sensitive time.

c. Lie on the head of the client's bed flat: This option is incorrect because lying the head of the client's bed flat is not appropriate for postmortem care. Elevating the head of the bed is essential to prevent blood pooling and discoloration of the client's face and neck, which can occur when the body is in a supine position for an extended period. Maintaining proper positioning also helps preserve the dignity and appearance of the deceased individual during the family viewing. Therefore, the nurse should ensure that the bed is appropriately positioned based on facility protocols and the client's condition.

d. Ask the family if they want to participate in postmortem care: Correct. Involving the family in postmortem care can be an important part of the grieving process and is considered a respectful practice if they wish to participate. By asking the family for their preferences and offering them the opportunity to participate in caring for their loved one, the nurse demonstrates sensitivity and respect for their cultural and personal beliefs. This approach allows the family to be actively involved in the final moments of their loved one's care and helps facilitate closure and acceptance during the grieving process.

In summary, the correct answer is d because asking the family if they want to participate in postmortem care ensures that their preferences and cultural beliefs are respected and accommodated during the family viewing. This approach fosters a supportive and dignified environment for the family as they say goodbye to their loved one.

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Correct Answer is C

Explanation

Choice A rationale:

Relocating the sensor every 8 hours is not necessary when obtaining oxygen saturation readings unless there is a specific clinical reason to do so, such as skin irritation or poor perfusion at the sensor site. Frequent relocation can cause unnecessary disruption for the patient.

Choice B rationale:

Waiting 10 seconds after placing the probe before obtaining the oxygen saturation reading is not required. Modern pulse oximeters provide real-time readings, and there is no need to wait after placing the probe. The reading is usually stable within seconds.

Choice C rationale:

Choosing a finger with a capillary refill time of less than 2 seconds is an essential consideration when obtaining oxygen saturation readings. Capillary refill time is a measure of peripheral perfusion, and choosing a finger with good perfusion ensures accurate oxygen saturation measurements.

Choice D rationale:

Placing the sensor probe on the same extremity as an electronic blood pressure cuff is generally acceptable. However, it is crucial to ensure that the sensor does not interfere with the blood pressure cuff's function and that it is securely attached to the patient's finger for accurate readings.

A. Hyperreflexia. B. Tinnitus with ear pain. C. Diplopia. D. Skin rash with fever.

Correct Answer is D

Explanation

Choice A rationale:

Hyperreflexia is not a common manifestation of Stevens-Johnson syndrome (SJS) SJS typically presents with skin and mucous membrane involvement, such as a skin rash, blistering, and mucosal lesions. Hyperreflexia is more commonly associated with neurological conditions, and it is not a typical symptom of SJS.

Choice B rationale:

Tinnitus with ear pain is not a characteristic manifestation of Stevens-Johnson syndrome (SJS) SJS primarily affects the skin and mucous membranes and does not typically involve the ears or auditory system. Tinnitus with ear pain could be related to other ear or auditory issues but is not associated with SJS.

Choice C rationale:

Diplopia (double vision) is not a typical manifestation of Stevens-Johnson syndrome (SJS) SJS primarily presents with skin and mucous membrane symptoms, including a rash, blisters, and mucosal lesions. Diplopia is more commonly associated with eye conditions or neurological disorders and is not a direct symptom of SJS.

Choice D rationale:

Skin rash with fever is a crucial manifestation to monitor and report in a client taking allopurinol because it can be indicative of Stevens-Johnson syndrome (SJS) Allopurinol is known to be associated with severe skin reactions like SJS, which can initially present as a skin rash with fever. Early recognition and reporting of this symptom are essential to prevent further complications. SJS is a medical emergency that requires immediate intervention.

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A nurse is preparing a client's body for a postmortem family viewing. Which of the following actions should the nurse take?

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A nurse is preparing a client's body for a postmortem family viewing.
Which of the following actions should the nurse take?