Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body?
A. Remove dentures.
Removing dentures is a step often performed during post-mortem care but may not necessarily need to be completed before family viewing, especially if the dentures are normally worn by the deceased.
B. Apply a shroud around the body with a visible identification tag.
Applying a shroud with a visible identification tag is an important step for dignified covering and identification but might be more appropriate after the family has viewed the body.
C. Clean soiled areas of the body.
This is the most appropriate action to ensure the body appears as dignified and comfortable as possible for family viewing. It involves cleaning any visible soiled areas to provide a respectful presentation to the family.
D. Place the client's head in a dependent position.
Placing the client's head in a dependent position is not typically necessary or recommended in this context. The goal is to ensure the body appears as natural and dignified as possible.
This question is an excerpt from Nurse Dive's nursing test bank - LPN ATI fundamental proctored exam. Take the full exam now
Full Explanation
A. Remove dentures:
- Removing dentures is a step often performed during post-mortem care but may not necessarily need to be completed before family viewing, especially if the dentures are normally worn by the deceased.
B. Apply a shroud around the body with a visible identification tag:
- Applying a shroud with a visible identification tag is an important step for dignified covering and identification but might be more appropriate after the family has viewed the body.
C. Clean soiled areas of the body:
- This is the most appropriate action to ensure the body appears as dignified and comfortable as possible for family viewing. It involves cleaning any visible soiled areas to provide a respectful presentation to the family.
D. Place the client's head in a dependent position:
- Placing the client's head in a dependent position is not typically necessary or recommended in this context. The goal is to ensure the body appears as natural and dignified as possible.
Similar Questions
A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?
A. Bone pain
Bone pain: Bone pain is not a characteristic finding of hypomagnesemia. Hypomagnesemia is an electrolyte imbalance, and bone pain is not a typical symptom associated with it.
B. Drowsiness
Drowsiness: Drowsiness may occur in hypomagnesemia, but it is not a specific or characteristic sign of this condition. Other electrolyte imbalances and medical conditions can also cause drowsiness.
C. Bowel hypomotility
Bowel hypomotility: Hypomagnesemia can cause bowel hypomotility (decreased bowel movements), but it is not the most specific finding associated with this condition.
D. Positive Chvostek's sign
Positive Chvostek's sign: Correct. Hypomagnesemia can lead to neuromuscular irritability, and a positive Chvostek's sign is a clinical manifestation of this condition. A positive Chvostek's sign is elicited by tapping the facial nerve (at the level of the zygomatic arch) and observing the atwitching of the facial muscles, which indicates increased neuromuscular excitability.
Full Explanation
A. Bone pain: Bone pain is not a characteristic finding of hypomagnesemia. Hypomagnesemia is an electrolyte imbalance, and bone pain is not a typical symptom associated with it.
B. Drowsiness: Drowsiness may occur in hypomagnesemia, but it is not a specific or characteristic sign of this condition. Other electrolyte imbalances and medical conditions can also cause drowsiness.
C. Bowel hypomotility: Hypomagnesemia can cause bowel hypomotility (decreased bowel movements), but it is not the most specific finding associated with this condition.
D. Positive Chvostek's sign: Correct. Hypomagnesemia can lead to neuromuscular irritability, and a positive Chvostek's sign is a clinical manifestation of this condition. A positive Chvostek's sign is elicited by tapping the facial nerve (at the level of the zygomatic arch) and observing a
twitching of the facial muscles, which indicates increased neuromuscular excitability.
A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?
A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds.
Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.Capillary refill is assessed to evaluate peripheral perfusion.
B. Use an adhesive oximetry probe for a client who has a latex allergy.
Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C. Remove polish from the client's fingernail before applying the oximetry probe.
Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D. Lubricate the tip of the oximetry probe.
Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.
Full Explanation
A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.
Capillary refill is assessed to evaluate peripheral perfusion.
B. Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C. Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D. Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.
A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?
A. Heart rate 62/min
Heart rate 62/min: A heart rate of 62 beats per minute is within the normal range for many adults and may not require immediate reporting unless it is a significant change from the client's baseline.
B. Urine output of 200 mL per 8 hr
Urine output of 200 mL per 8 hr: Correct. A urine output of 200 mL in 8 hours is considered low and may indicate inadequate kidney perfusion or function. It should be reported to the provider as it could be a sign of renal impairment or dehydration.
C. Pulse oximetry 95% on room air
Pulse oximetry 95% on room air: A pulse oximetry reading of 95% on room air is within the normal range for oxygen saturation in most healthy individuals. It does not require immediate reporting unless the client has a specific condition or baseline that warrants concern.
D. BP 112/76 mm Hg
BP 112/76 mm Hg: Blood pressure of 112/76 mm Hg is within the normal range for many adults and may not require immediate reporting unless there are specific concerns related to the client's medical history or condition.
Full Explanation
A. Heart rate 62/min: A heart rate of 62 beats per minute is within the normal range for many adults and may not require immediate reporting unless it is a significant change from the client's baseline.
B. Urine output of 200 mL per 8 hr: Correct. A urine output of 200 mL in 8 hours is considered low and may indicate inadequate kidney perfusion or function. It should be reported to the provider as it could be a sign of renal impairment or dehydration.
C. Pulse oximetry 95% on room air: A pulse oximetry reading of 95% on room air is within the normal range for oxygen saturation in most healthy individuals. It does not require immediate reporting unless the client has a specific condition or baseline that warrants concern.
D. BP 112/76 mm Hg: Blood pressure of 112/76 mm Hg is within the normal range for many adults and may not require immediate reporting unless there are specific concerns related to the client's medical history or condition.