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 D

Explanation

A. Attach a blood pressure cuff to the client's upper arm: A blood pressure cuff is not involved in obtaining a 12-lead ECG. Although blood pressure may be assessed separately, it is not part of the ECG procedure itself and would not aid in capturing accurate cardiac electrical activity.

B. Assist the client to the orthopneic position: The orthopneic position, which involves leaning forward, is used to ease breathing difficulties, not for ECG recording. For an ECG, the client should be lying flat or in a semi-reclined supine position to ensure consistent and accurate electrode placement.

C. Tell the client to expect a mild stinging sensation during the test: A 12-lead ECG is a painless, non-invasive procedure. Electrodes are applied to the skin's surface to measure electrical activity; there should be no pain or stinging involved unless the skin is abraded during preparation.

D. Instruct the client to remain as still as possible during the recording: Movement can cause artifacts on the ECG tracing, making it difficult to interpret accurately. Instructing the client to stay still helps ensure a clean recording and minimizes interference from muscle tremors or motion.

A. Pain relieved by the prone position B. Decreased WBC count C. Hyperactive bowel sounds D. Epigastric pain

Correct Answer is D

Explanation

A. Pain relieved by the prone position: Pain from acute pancreatitis is typically not relieved by lying prone. Clients often find some relief by sitting up, leaning forward, or assuming a fetal position, as these positions reduce pressure on the inflamed pancreas.

B. Decreased WBC count: Acute pancreatitis usually triggers an inflammatory response, leading to an elevated white blood cell (WBC) count, not a decreased one. Leukocytosis is a common laboratory finding associated with the body's reaction to inflammation and possible infection.

C. Hyperactive bowel sounds: In acute pancreatitis, bowel sounds are often decreased or absent due to paralytic ileus. Hyperactive bowel sounds would be more suggestive of other gastrointestinal disturbances such as diarrhea or early intestinal obstruction.

D. Epigastric pain: Severe, persistent epigastric pain that may radiate to the back is the hallmark symptom of acute pancreatitis. This pain is typically sudden in onset and worsens after eating or drinking, especially fatty foods.

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