The hospice nurse cares for a client who just died.
Which actions should the nurse take? Select all that apply.

Make sure that the physician has completed and signed the death certificate.

Follow agency policies to remove all tubes and lines from the body.

Remove the body to the morgue or funeral home immediately after death.

Allow family or significant other to perform religious and cultural customs.

Provide privacy for the family and significant others with the deceased.

Answer and Explanation

Correct Answer : D,E

Providing post-mortem care requires knowledge of legal requirements, hospital protocols, and psychosocial support. The nurse must apply principles of cultural sensitivity and respect for the deceased while ensuring that administrative and physical care tasks align with the specific circumstances of death.

Choice A rationale

While a physician or authorized practitioner must pronounce death and sign the certificate, it is not the immediate responsibility of the nurse to ensure the signature is completed before beginning initial post-mortem nursing care.

Choice B rationale

Removing tubes is often prohibited if an autopsy is required, especially in sudden or suspicious deaths. The nurse must first verify the cause of death and institutional policy before disturbing any medical devices or invasive lines.

Choice C rationale

Removing the body immediately is insensitive and may interfere with the grieving process. Families should be given adequate time to spend with the deceased to begin their emotional processing and perform any necessary rituals.

Choice D rationale

Allowing for religious and cultural customs is a core component of holistic nursing care. This respects the dignity of the deceased and supports the family's coping mechanisms during the immediate period following a significant loss.

Choice E rationale

Providing privacy is essential for the family to express grief without observation. This therapeutic environment allows for intimate goodbyes and facilitates the beginning of the mourning process in a respectful and safe hospital or hospice setting.

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Correct Answer is B

Explanation

Managing increased intracranial pressure requires applying knowledge of osmotic therapy, cerebral perfusion, and neurological positioning. Nurses must prioritize interventions that rapidly reduce cerebral edema while maintaining physiological stability and preventing herniation in patients with traumatic brain injuries or intracranial hypertension.

Choice A rationale

Pentobarbital is a barbiturate used for medically induced comas to reduce cerebral metabolic demand. While effective for refractory intracranial hypertension, it is typically a secondary or tertiary intervention rather than the immediate priority for an upward trend in pressure.

Choice B rationale

Mannitol is an osmotic diuretic that creates an osmotic gradient, pulling fluid from the cerebral interstitial space into the vascular compartment. This rapidly reduces brain volume and intracranial pressure, making it the first-line pharmacological priority for acute elevations.

Choice C rationale

Hyperventilation decreases PaCO2, causing cerebral vasoconstriction and reduced blood volume. However, excessive hyperventilation can cause cerebral ischemia. Increasing the rate to 20 should only be done under specific medical direction and is not the primary nursing priority here.

Choice D rationale

Proper positioning, such as head of bed elevation and avoiding neck flexion, facilitates venous drainage from the brain. While important, it is a supportive measure and less effective than osmotic diuretics for treating an acute, upward trend.

A. Protect the skin graft from direct sunlight. B. Continue physical therapy. C. Use cosmetic camouflage techniques. D. Maintain a low-protein, high-fiber diet.

Correct Answer is A

Explanation

This clinical scenario focuses on postoperative care for split-thickness skin grafts and integumentary rehabilitation. Knowledge of tissue fragility, ultraviolet radiation sensitivity, and wound healing phases is required to prevent graft failure, hyperpigmentation, and secondary injury during the remodeling phase.

Choice A rationale

Newly grafted skin lacks melanocytes and the protective epidermal barrier, making it highly susceptible to ultraviolet damage. Direct sunlight can cause severe sunburn and permanent hyperpigmentation. Protection ensures long-term graft viability and prevents tissue degradation.

Choice B rationale

Physical therapy is vital to prevent contractures and maintain range of motion in burned limbs. While necessary for functional recovery, it is not the immediate priority over preventing physical damage to the fragile graft site from environmental factors.

Choice C rationale

Cosmetic camouflage helps manage the psychological impact of scarring and skin discoloration. While important for holistic recovery and body image, it is a psychosocial intervention that ranks lower than physiological protection of the surgical graft site.

Choice D rationale

Burn recovery requires a high-protein, high-calorie diet to support tissue synthesis and positive nitrogen balance. A low-protein diet would be contraindicated as it impairs collagen formation and delays wound healing in recovering burn patients.

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The hospice nurse cares for a client who just died. Which actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with a closed head injury sustained in a motor vehicle accident. The nurse notes that the client's intracranial pressure (ICP) shows an upward trend. Which action should the nurse prioritize?

Correct Answer is B

Explanation

The nurse in the burn unit provides discharge instructions for a client who received a skin graft due to deep partial-thickness burns from a work accident at a chemical plant. Which instruction should the nurse prioritize?

Correct Answer is A

Explanation

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The hospice nurse cares for a client who just died.
Which actions should the nurse take? Select all that apply.