A nurse is providing postmortem care for a client. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Determine the family's preferences about care of the body.

Apply identifying name tags onto the client.

Verify that the provider has certified the client's death.

Remove all equipment and tubes from the client's body.

Answer and Explanation

The Correct Answer is C,A,D,B

Verify that the provider has certified the client's death: Before any postmortem care is initiated, it's crucial to confirm that the client has indeed passed away. This verification is typically done by a healthcare provider, such as a physician or nurse practitioner, who examines the client, checks for signs of life, and makes an official declaration of death.

Determine the family's preferences about care of the body: After the client's death has been certified, the healthcare team should communicate with the family or next of kin to inquire about their preferences regarding the care of the deceased. Families may have specific cultural, religious, or personal requests regarding postmortem care procedures, and it's essential to respect and accommodate these preferences whenever possible.

Remove all equipment and tubes from the client's body: This step involves the removal of any medical equipment, devices, or tubes that may have been in use during the client's medical care. This can include items such as intravenous (IV) lines, catheters, ventilator tubing, and monitoring equipment. Ensuring that all equipment is removed is not only a matter of dignity but also helps prepare the body for viewing by the family, if desired.

Apply identifying name tags onto the client .To maintain accurate identification and tracking of the deceased client, it's common practice to attach identifying name tags or labels to the body. These tags typically contain essential information, such as the client's name, medical record number, and date of birth. This step helps prevent any confusion or mix-up of identities during postmortem procedures and transport.

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Correct Answer is C

Explanation

This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.

The following examples may not require an incident report:

A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.

A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.

A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.

A. The AP inserts the probe with a straight, forward motion. B. The AP positions the client facing her. C. The AP pulls the pinna up and back. D. The AP points the probe posteriorly.

Correct Answer is C

Explanation

Choice A Reason:

Inserting the probe with a straight, forward motion is not correct because the ear canal is curved, and this technique could lead to inaccurate readings or discomfort.

Choice B Reason:

The AP positions the client facing her. The position of the client's face is not relevant to taking a tympanic temperature. The client can face any direction during the procedure.

Choice C Reason:

Pulling the pinna up and back straightens the ear canal in adults, allowing for a more accurate reading when taking a tympanic temperature.

Choice D Reason:

Pointing the probe posteriorly is incorrect as the probe should be pointed towards the tympanic membrane, which usually requires slight angling to align with the ear canal.

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A nurse is providing postmortem care for a client. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

Correct Answer is C

Explanation

A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Correct Answer is C

Explanation

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