Nokea
A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds
- C. Place the client in a high-Fowler's position
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is important to maintain a dignified appearance for the deceased client and to create a peaceful and respectful image for the family during their visit. Crossing the client's arms (A) or placing them in a high-Fowler's position (C) may not be necessary and can be considered unnecessary handling of the body. Removing the client's dentures (D) is not typically part of postmortem care unless specifically instructed. Holding the eyes shut briefly is a culturally sensitive and respectful practice that can help create a serene appearance for the family.
You may also like to solve these questions
Which of the following is an appropriate action by the nurse?
- A. Suggest rinsing his mouth with an alcohol-based mouth wash
- B. Provide humidification of the room air.
- C. Offer the client saltine crackers between meals
- D. Instruct the client on the use of esophageal speech
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Humidification helps to moisturize the air, making it easier for the client to breathe, especially if they have dry mouth or throat. This can improve comfort and prevent irritation. Choice A is incorrect because alcohol-based mouthwash can further dry out the mouth. Choice C is incorrect as saltine crackers can exacerbate dry mouth. Choice D is incorrect as esophageal speech is not related to addressing dry mouth.
For each finding. click to specify if the finding is consistent with pancreatitis or peritonitis Each finding may support more than one disease process.
- A. Bloody stools
- B. Hyperbilirubinemia
- C. Abdominal pain
- D. Elevated WBC court
Correct Answer: A,B,C,D
Rationale: The correct answer is .
Rationale:
1. Bloody stools can be seen in both pancreatitis and peritonitis due to gastrointestinal bleeding.
2. Hyperbilirubinemia is a common finding in pancreatitis due to obstruction of the bile duct by edema or inflammation.
3. Abdominal pain is a hallmark symptom of both pancreatitis and peritonitis, indicating inflammation or irritation of the abdominal structures.
4. Elevated WBC count is a sign of infection or inflammation, which can be present in both pancreatitis and peritonitis.
Summary:
- Bloody stools: Supports both pancreatitis and peritonitis.
- Hyperbilirubinemia: Supports pancreatitis.
- Abdominal pain: Supports both pancreatitis and peritonitis.
- Elevated WBC count: Supports both pancreatitis and peritonitis.
Other choices are incorrect because they do not align with the typical clinical presentations of pancreatitis
Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.
Which of the following actions should the nurse take first?
- A. Teach the client how to insert the diaphragm
- B. Document the client's level of understanding about potential adverse effects.
- C. Supervise return demonstration of diaphragm use
- D. Determine the client's knowledge about diaphragm use
Correct Answer: D
Rationale: Assessing the client’s current knowledge is the first step in patient education.
Which of the following positions should the nurse take to place the client at ease?
- A. Sit in a chair next to the bed
- B. Stand at the side of the bed.
- C. Sit on the bed next to the client.
- D. Stand at the foot of the bed
Correct Answer: A
Rationale: The correct answer is A: Sit in a chair next to the bed. This position allows the nurse to be at eye level with the client, promoting a sense of equality and rapport. Sitting also conveys a sense of attentiveness and availability for conversation. Standing at the side of the bed (B) may create a sense of distance. Sitting on the bed next to the client (C) may invade personal space. Standing at the foot of the bed (D) can be perceived as intimidating.