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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Dexamethasone is a potent corticosteroid used to reduce cerebral edema in brain tumor patients. Prioritizing care requires identifying life-threatening neurological changes or severe medication side effects, applying knowledge of intracranial pressure, glucose metabolism, and the hierarchy of clinical needs.
Choice A rationale
Acute loss of orientation to self indicates a significant decline in neurological status or increased intracranial pressure. This is a medical emergency requiring immediate intervention to prevent brain herniation, outweighing stable physical side effects of steroid therapy.
Choice B rationale
Weight gain is a common side effect of long-term dexamethasone use due to fluid retention and increased appetite. While it requires monitoring, it is an expected systemic effect and does not represent an immediate life-threatening crisis.
Choice C rationale
Insomnia is a known side effect of corticosteroids because they can interfere with the circadian rhythm and stimulate the central nervous system. It affects the client's comfort but does not indicate immediate physiological or neurological compromise.
Choice D rationale
Glucocorticoids cause hyperglycemia; 350 mg/dL is high compared to the normal fasting range of 70 to 100 mg/dL. While it requires insulin or dosage adjustment, it is less urgent than an acute neurological deficit..
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}
Explanation
In the management of a sub-massive Pulmonary Embolism (PE), all of these actions are indicated because the client will be started on a rigorous anticoagulation regimen (typically a transition from Heparin to Warfarin/DTI).
- aPTT & Protamine Sulfate: Indicated for monitoring and reversing Heparin therapy, which is usually the initial treatment for an acute PE.
- INR & Phytonadione: Indicated for monitoring and reversing Warfarin (Coumadin) therapy, which is often started simultaneously with Heparin for long-term management.
- Hematocrit: Essential to monitor for internal bleeding or occult blood loss while on anticoagulants.
- Platelet levels: Necessary to screen for Heparin-Induced Thrombocytopenia (HIT), a serious complication of heparin therapy.
- Bleeding/Bruising Assessment: This is the most critical nursing assessment for any client receiving anticoagulation to ensure safety and catch hemorrhage early.
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