A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

Ask the client's family about cultural or religious practices regarding postmortem care.

Remove the client's dentures from their mouth before rigor mortis begins.

Turn on all the lights in the room before the family views the client's body.

Position the client's bed flat without a pillow under their head.

Answer and Explanation

The Correct Answer is A

A. Ask the client's family about cultural or religious practices regarding postmortem care: Respecting the client's and family's cultural and religious preferences is an important aspect of providing dignified and individualized postmortem care. Some practices may have specific rituals that should be honored.

B. Remove the client's dentures from their mouth before rigor mortis begins: Dentures are usually placed back into the client's mouth, not removed, to maintain a natural facial appearance and support the facial structure before rigor mortis sets in.

C. Turn on all the lights in the room before the family views the client's body: Creating a calm, peaceful environment is preferred when the family views the body. Harsh lighting may feel overwhelming or intrusive during such an emotional time.

D. Position the client's bed flat without a pillow under their head: Elevating the head of the bed slightly and placing a pillow under the head can help prevent blood from pooling in the head and face, preserving a more natural appearance. Leaving the bed flat is not ideal.

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Correct Answer is C

Explanation

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL): A mildly elevated blood glucose level is not immediately life-threatening and can be managed after addressing more urgent issues. This client is stable at the moment.

B. A client who has a spinal cord injury and needs a dressing change: While important for preventing infection, a scheduled dressing change is not an immediate threat to the client’s life or health and can be safely performed after more urgent concerns are addressed.

C. A client who has a temperature of 38.4° C (101.1° F) and appears confused: Fever and new-onset confusion suggest a possible infection, such as sepsis or urinary tract infection, especially in older adults. This situation indicates a potential life-threatening condition and requires immediate assessment and intervention.

D. A client who had a hip arthroplasty and is requesting pain medication: Managing pain is important, but it is not immediately life-threatening. After addressing the client with fever and confusion, attending to the client's pain needs would be appropriate.

A. Deep tendon patellar reflex B. Blood pressure C. Heart rate D. Edema

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Deep tendon patellar reflex: The client's deep tendon reflexes improved from being hyperreflexive at 4+ to normal at 2+ without clonus on Day 2. This is a positive sign because hyperreflexia increases seizure risk in preeclampsia, and normalization indicates stabilization of neurological irritability.
Blood pressure: Although still elevated, the blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg by Day 2. While not normal yet, the trend toward lower values represents improvement in controlling the severe hypertension associated with preeclampsia.
Heart rate: The client's heart rate increased slightly from 72/min to 90/min. While still within normal range, this change reflects a more responsive and stable cardiovascular status, and there are no signs of bradycardia or distress, supporting mild improvement.
Edema: The client continues to have +3 pitting edema bilaterally, with no reported reduction compared to the initial assessment. Persistent severe edema suggests that fluid balance issues from preeclampsia have not yet improved and still require active management.

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A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility has just received change-of-shift report. Which of the following clients should the nurse attend to first?

Correct Answer is C

Explanation

The nurse is continuing to assist with the care of the client. For each finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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