Nokea
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Place a name tag on the body.
- B. Obtain the pronouncement of death from the provider.
- C. Remove tubes and indwelling lines.
- D. Wash the client's body.
- E. Ask the client's family members if they would like to view the body.
Correct Answer: B, E, C, D, A
Rationale: 1. Obtain the pronouncement of death from the provider (B): This is the first step to officially confirm the client's passing.
2. Ask the client's family members if they would like to view the body (E): Providing support to the family is crucial.
3. Remove tubes and indwelling lines (C): This step is necessary to prepare the body for respectful handling.
4. Wash the client's body (D): Maintaining dignity and cleanliness is important.
5. Place a name tag on the body (A): This ensures proper identification for all involved.
In summary, obtaining the pronouncement of death is the priority, followed by addressing the emotional needs of the family, preparing the body, and ensuring proper identification. Removing tubes and washing the body come before placing the name tag.
You may also like to solve these questions
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the client in a semi-lying position.
- B. Instill 15 mL of irrigation fluid into the catheter with each flush.
- C. Subtract the amount of irrigant used from the client's urine output.
- D. Perform the irrigation using a 20-mL syringe.
Correct Answer: C
Rationale: The correct answer is C: Subtract the amount of irrigant used from the client's urine output. This is the correct action because when using open irrigation technique, the nurse needs to account for the amount of irrigant introduced into the catheter to accurately assess the client's urine output. By subtracting the amount of irrigant used from the total output, the nurse ensures an accurate measurement of the client's urine output. This is crucial for monitoring the client's renal function and fluid balance.
Choice A is incorrect as the client should ideally be in a supine position during catheter irrigation to prevent spillage. Choice B is incorrect as the amount of irrigation fluid instilled should typically be equal to the amount of urine output, not a fixed amount. Choice D is incorrect as a 60-mL syringe is usually recommended for catheter irrigation to avoid excessive force and pressure on the catheter.
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
- A. Increase in hematocrit.
- B. Increase in respiratory rate.
- C. Decrease in heart rate.
- D. Decrease in capillary refill time.
Correct Answer: C
Rationale: The correct answer is C: Decrease in heart rate. Administering 0.9% sodium chloride would help rehydrate the client, leading to an increase in blood volume and improved cardiac output. As a result, the heart doesn't have to work as hard, leading to a decrease in heart rate, indicating successful treatment.
Incorrect choices:
A: Increase in hematocrit - This would indicate dehydration, not successful treatment.
B: Increase in respiratory rate - This could be a sign of respiratory distress, not related to fluid volume correction.
D: Decrease in capillary refill time - This could indicate improved peripheral circulation, but not a direct indicator of successful fluid resuscitation.
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
- A. Verify the client's name on their identification bracelet with the medication administration record.
- B. Call the pharmacy to determine whether the client's medications are available.
- C. Compare the client's home medications with the provider's prescriptions.
- D. Place the client's home medication bottles in a secure location.
Correct Answer: C
Rationale: The correct answer is C: Compare the client's home medications with the provider's prescriptions. This is essential for medication reconciliation to ensure accuracy and prevent medication errors. By comparing the client's home medications with the provider's prescriptions, the nurse can identify discrepancies, address any missing medications or duplications, and ensure the client receives the correct treatment. Verifying the client's name (A) is important for patient safety but not directly related to medication reconciliation. Calling the pharmacy (B) may provide some information but does not involve comparing home medications with provider prescriptions. Placing home medication bottles in a secure location (D) is not part of the medication reconciliation process.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage.
- B. Notify the pharmacy when wasting the medication.
- C. Lock the remaining medication in the controlled substances cabinet.
- D. Dispose of the vial with the remaining medication in a sharps container.
Correct Answer: C
Rationale: The correct answer is C: Lock the remaining medication in the controlled substances cabinet. This is the correct action because opioids are controlled substances that require strict security measures to prevent diversion or misuse. By locking the remaining medication in the controlled substances cabinet, the nurse ensures that it is securely stored and accounted for.
Choice A: Asking another nurse to observe the medication wastage is unnecessary in this situation as the remaining medication should be properly secured rather than observed.
Choice B: Notifying the pharmacy when wasting the medication may be required for documentation purposes, but it does not address the immediate need to secure the remaining medication.
Choice D: Disposing of the vial with the remaining medication in a sharps container is incorrect as it does not follow proper protocol for handling controlled substances.
In summary, choice C is the correct action as it aligns with the necessary security measures for handling opioids, while the other choices do not address the specific requirements for controlled substances.
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
- A. Insert the catheter at a 45-degree angle.
- B. Place the client's arm in a dependent position.
- C. Shave excess hair from the insertion site.
- D. Initiate IV therapy in the veins of the hand.
Correct Answer: A
Rationale: The correct answer is A: Insert the catheter at a 45-degree angle. When inserting a peripheral IV catheter for an older adult client, the nurse should aim to insert the catheter at a 45-degree angle to reduce the risk of complications such as infiltration. Inserting at this angle helps to ensure proper placement in the vein and reduces the likelihood of the catheter slipping out or causing discomfort to the client. Placing the client's arm in a dependent position (B) is not necessary and could potentially cause unnecessary discomfort. Shaving excess hair from the insertion site (C) is not recommended as it can irritate the skin and increase the risk of infection. Initiating IV therapy in the veins of the hand (D) may not be the best choice for an older adult client due to potential fragility of hand veins and difficulty with vein accessibility.