The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A. Request the family members leave the client's room: Family members may choose to stay if they wish, and they should be allowed to participate or be present during postmortem care if it aligns with their emotional needs or cultural practices. Forcing them to leave is not appropriate unless required for specific procedures.

B. Place dentures in the client's mouth: Placing dentures helps maintain the natural shape and appearance of the face, offering a more familiar and comforting appearance for the family during viewing. This is an important step in preparing the body respectfully.

C. Remove the client's personal hair pieces: Hairpieces should be left in place unless the family or facility policy requests otherwise. Removing them without need can alter the client’s appearance and potentially distress the family.

D. Lower the head of the client's bed: The head of the bed should be elevated slightly, not lowered, to prevent blood from pooling in the head and face, which could cause discoloration and swelling before the family views the body.

A. Report the blood pressure reading to the charge nurse: While notifying the charge nurse is important, the nurse should first validate the high reading by rechecking the blood pressure. Acting on a single, unverified reading could lead to unnecessary interventions or missed opportunities for accurate assessment.

B. Administer an antihypertensive medication: Administering antihypertensive medication based solely on a report without rechecking the blood pressure could be unsafe. Verification ensures that treatment is based on accurate clinical data and prevents unnecessary medication administration.

C. Remeasure the client's blood pressure: The first action should always be to recheck an unusually high or abnormal vital sign reading to confirm its accuracy. Errors can occur during measurement, and accurate confirmation is critical before proceeding with further interventions in a client with chronic kidney failure.

D. Instruct the client to remain in bed: While keeping the client in bed can help prevent complications if severe hypertension is confirmed, it is not the priority action. Verifying the blood pressure reading must occur first to determine the appropriate course of action.