Nokea
A nurse is assisting with the postmortem care of a client whose partner is at the bedside. Which of the following actions should the nurse take?
- A. Direct the partner to leave and return once postmortem care is complete.
- B. Instruct the partner not to touch the client's body.
- C. Place the client's personal belongings in a safe location in the facility.
- D. Ask the partner about any rituals they would like to be performed.
Correct Answer: D
Rationale: Asking the partner about rituals respects their cultural or personal preferences, supporting their grieving process. Forcing them to leave or restricting touch is insensitive, and belongings are a secondary concern.
You may also like to solve these questions
A nurse is reinforcing information with a client who wishes to complete their advance directives. Which of the following statements should the nurse make?
- A. You must have advance directives in place in order to refuse recommended treatment.
- B. An attorney is needed in order for you to name a designee in your health care proxy.
- C. You can decline to have certain medical procedures performed in your living will.
- D. A living will can be an oral statement that you agree upon with your provider.
Correct Answer: C
Rationale: You can decline to have certain medical procedures performed in your living will' accurately describes its purpose. Refusal rights exist without directives, an attorney isn't required, and a living will must be written.
A nurse is reinforcing teaching with a client who needs to increase vitamin C intake to promote wound healing. Which of the following foods should the nurse recommend as the best source of vitamin C?
- A. 1 small banana
- B. 1 medium fresh green pear
- C. 1 small pink grapefruit
- D. 1 small apple with the skin
Correct Answer: C
Rationale: A small pink grapefruit contains 38.4 mg of vitamin C, the highest among the options, making it the best source for wound healing. Banana, pear, and apple have significantly less.
A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?
- A. Using an oral care sponge swab moistened with cool water to clean the client's mouth.
- B. Wearing clean gloves to perform mouth care for the client.
- C. Lowering the side rail on the side of the bed where they will stand to perform mouth care.
- D. Using two gloved fingers to open the client's mouth for cleaning.
Correct Answer: D
Rationale: Using two gloved fingers to open the client's mouth for cleaning is unsafe. This method can cause injury to the AP if the patient bites down reflexively. A padded tongue blade should be used instead. The other actions are appropriate for mouth care in an unconscious client.
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 125/85 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Measure the client's BP in the other arm.
- C. Deflate the cuff faster when repeating the BP measurement.
- D. Request a prescription for an antihypertensive medication.
Correct Answer: B
Rationale: Measuring the client's BP in the other arm is the correct action to confirm the accuracy of the reading and rule out errors. A narrower cuff or faster deflation can skew results, and requesting medication is premature without verifying the elevation and assessing its cause.
A nurse is providing teaching with a client who has severe arthritis and has difficulty with stairs. What should the nurse include in the teaching?
- A. Keep your eyes on your feet when ascending or descending the stairs.
- B. Maintain your arms in a slightly bent position when using the handrails.
- C. Move your right leg forward as you lower yourself to the next step.
- D. Support yourself with the handrail when transferring to or from the stairs.
Correct Answer: B
Rationale: Maintaining arms in a slightly bent position when using handrails enables the client to use them as support and reduces stress on the arms and shoulders. The other options can lead to imbalance, instability, or strain.