Question

A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

Answer 1

Correct Answers:

Place an identification tag on the outside of the client's shroud.

Rationale :

🟩 For clients requiring autopsy, it is important to maintain proper identification by placing a tag on the outside of the shroud and sometimes on the ankle or wrist.

🟩 The body must not be altered, which means no tubes or lines should be removed if an autopsy is ordered.

🟩 Documenting the time of death and actions taken is the nurse’s responsibility—not delegated.

🟩 Dentures should be kept with the body or documented and secured per facility policy.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Obtain verbal consent from the end.

Rationale :

🟪 Indwelling catheterization is a non-surgical invasive procedure and requires express verbal consent, not a written form.

🟪 Nurses may proceed after ensuring the client understands the procedure and verbally agrees.

🟪 Written consent is typically required for surgical or high-risk procedures, not for routine ones like catheterization.

🟪 Documentation of the verbal consent is still essential in the medical record.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Use a filter needle to aspirate the medication

Rationale :

🟥 Ampules are glass containers, and breaking them can create glass shards.

🟥 Filter needles are used to aspirate medication from ampules to prevent contamination with glass particles.

🟥 Air should not be injected into ampules, and the tip does not need alcohol prep after opening.

🟥 Diluent is only required if the medication is in powder form, which ampules typically are not.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Place a pillow between the client's legs prior to logrolling.

Rationale :

🟨 Following a laminectomy, it's critical to maintain spinal alignment during repositioning.

🟨 A pillow between the legs keeps hips and spine aligned during logrolling, preventing torsion or twisting.

🟨 Arms should remain across the chest (not above the head), and positioning in semi-Fowler’s may increase spinal pressure.

🟨 Proper logrolling requires a coordinated team effort and spine precautions.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Performing pelvic-muscle exercises is correct.

Rationale :

🟦 Pelvic floor (Kegel) exercises strengthen the muscles that support the bladder and urethra, improving urinary control.

🟦 These exercises are a primary intervention in stress and urge incontinence management.

🟦 Training the bladder by voiding every 2 to 3 hours, not 5 hours, is more appropriate.

🟦 Citrus juices can irritate the bladder, worsening symptoms in some patients.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Urinate prior to collecting the stool specimen

Rationale :

🟩 The client should void before collecting stool to prevent urine contamination, which can lead to false results.

🟩 Vitamin C supplements should be stopped 72 hours prior, not just 24.

🟩 Red meats, not pork specifically, may cause a false positive; 3 days' abstention is usually enough.

🟩 A thin smear of stool is sufficient for accurate testing.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

🟨 The correct sequence for tracheostomy care ensures a sterile, safe, and effective procedure.

🟨 – Pouring sterile saline prepares the solution for cleaning.

🟨 – Cleansing the stoma site removes superficial contaminants.

🟨 – Removing the inner cannula allows access for thorough cleaning.

🟨 – Scrubbing the cannula clears debris and secretions.

🟨 – Wiping the cannula ensures it is clean and dry before reinsertion.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Hyponatremia

Rationale :

🟥 Vomiting and diarrhea lead to excessive sodium loss, causing hyponatremia, a common electrolyte disturbance in fluid loss.

🟥 Signs include confusion, fatigue, muscle cramps, and risk of seizures in severe cases.

🟥 Potassium and calcium may also be lost but not as prominently or predictably as sodium.

🟥 Fluid replacement with electrolyte-balanced solutions is essential.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

The stoma appears dark in color.

Rationale :

🟧 A dark, dusky, or black stoma suggests compromised circulation or tissue necrosis, requiring immediate medical evaluation.

🟧 A healthy stoma should be moist, red, or pink and protrude slightly.

🟧 Light bleeding and minimal liquid stool drainage are normal post-op findings.

🟧 Any signs of ischemia or necrosis must be reported promptly.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

The stoma appears dark in color.

Rationale :

🟩 A dark, dusky, or black-colored stoma indicates poor blood flow, which could signal ischemia or necrosis. This is a medical emergency and must be reported to the provider immediately for further evaluation and potential surgical intervention.

🟩 A healthy stoma should be pink to red, moist, and protruding slightly, which reflects good perfusion.

🟩 While slight bleeding when touched is expected during the initial postoperative period, a dark color is not normal at any stage.

🟩 Prompt action is critical to prevent tissue death and further complications like sepsis or obstruction.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

2 :
A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

3 :
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

4 :
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

5 :
A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?

6 :
A nurse is reinforcing discharge teaching about fecal occult blood testing with include in the teaching?

7 :
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

8 :
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

9 :
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

10 :
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

QLexNursing

1 : A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

2 : A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

3 : A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

4 : A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

5 : A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?

6 : A nurse is reinforcing discharge teaching about fecal occult blood testing with include in the teaching?

7 : A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

8 : A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

9 : A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

10 : A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

1 :
A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

2 :
A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

3 :
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

4 :
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

5 :
A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?

6 :
A nurse is reinforcing discharge teaching about fecal occult blood testing with include in the teaching?

7 :
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

8 :
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

9 :
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

10 :
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?