Nur 340L-Final Exam Questions and Complete Solutions
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Course
NUR 340
Institution
NUR 340
Signs that death has occured -absence of heartbeat, respirations -pupils fixed -color turns to a waxen pallor as blood settles -body temperature drops -muscles, sphincters relax
What does federal and state laws require that institutions develop for events that occur after death? policies and proce...
Nur 340L-Final Exam Questions and
Complete Solutions
Signs that death has occured ✅-absence of heartbeat, respirations
-pupils fixed
-color turns to a waxen pallor as blood settles
-body temperature drops
-muscles, sphincters relax
What does federal and state laws require that institutions develop for events that occur
after death? ✅policies and procedures
What should policies and procedures for events after death include? ✅-requesting
organ or tissue donation
-autopsy
-certifying and documenting the occurence of a death
-providing safe and appropriate post mortem care
Post-mortem care: what can't the nurse delegate to a nursing assistive personnel?
✅organ/tissue donation and autopsy requests
Post-mortem care: What are the equipment pieces involved? ✅-bath towels
-washcloths
-washbasin
-scissors
-shroud kit with name tag
-documentation forms
Post-mortem care: what are the guidelines for physician or other designated health care
provider involvement? ✅-certifies the death and documents the time of death and
actions taken
-requests autopsy(an autopsy is sometimes required for death that occur under certain
circumstances)
-validate status of request for organ or tissue donation(maintain sensitivity to personal,
religious and cultural beliefs in the process)
Post-mortem care: How does the nurse provide sensitive and dignified nursing care to
the client and the family? ✅-note if you need to collect any specimens
-ask if the family wishes to participate in the preparation of the body(if no, offer to
arrange supportive company)
,-ask about family requests for body preparation(special clothing or religious artifacts, get
permission before shaving facial hair)
What are the 6 categories of the Morse Fall Risk scale? ✅-history of falls
-secondary diagnosis
-IV therapy
-ambulatory aid
-gait
-mental status
What are the scores for the Morse Fall Risk Scale? ✅No risk: 0-24, good basic nursing
care
Low Risk: 25-50, implement standard fall prevention interventions
High Risk: >51, implement high risk fall prevention intervention
How is each scale scored for the Morse Fall Risk Scale ✅Falls:
-25pts. if recent fall/fall during hospital stay
-25pts. if patient falls for first time
-0pt. if no fall
Secondary diagnosis:
-15pt. for more than 1 medical diagnosis
-0pt. no secondary diagnosis
IV therapy:
-20pt. for IV apparatus or heparin lock
-0pt. for none
Ambulatory aid:
-0pt. if walks without aid(even if assisted by nurse, use wheelchair or on bed rest,
doesn't get out of bed)
-15pts. if patient use crutches, cane walker
-30pt. if patient clutching furniture for support
Gait:
-0pts. normal gait
-10pt. stooped but able to lift head without loosing balance, short shuffled steps
-20pt. difficulty rising from chair(bounces several times before getting up), patients head
is down/watches the ground
Mental Status: ask if the patient thinks the'll be able to walk
-0pt. able is realistically able to make judgement on her/his walking abilities
, -15pts. patient doesn't respond to assessment, responds to question inappropriately or
unrealistic in answers given circumstances
Post-mortem care: what should be taken away from the body prior to care? ✅remove
all equipment, tubes and indwelling lines
(note that autopsy or organ donation often poses exceptional to removal so consult
agency policy in these situation)
Post-mortem care: what should be done to the body before covering the body?
✅cleanse the body thoroughly, maintaining safety standards for body fluids and
contamination when indicated, comb clients hair
put on clean gown(optional)
Post-mortem care: What should be done while covering the body? ✅-cover the body
with a clean sheet
-place head on a pillow and leave arms outside covers, if possible
-close eyes by gently holding them shut
-leave dentures in the mouth to maintain facial shape
-cover any signs of body trauma
Post-mortem care: How should you prepare the room before family comes? ✅-prepare
and clean environment
-deoderize room if needed
-lower lights
-provide box of tissues
Post-mortem care: what should you offer the family when they enter? ✅-option to view
the body
-the nurse or other support person to accompany them
-honor and respect individual choices
Post-mortem care: what should you encourage of the grievers? ✅to say good-bye in
their own ways; words, touch, singing, religious rituals, prayer
Post-mortem care: what atmosphere should you provide to grievers? ✅privacy,
unrushed
-assess family members need or desire for your presence at this time
-if you leave tell them how to reach you
Post-mortem care: What should be done with the personal belongings? ✅determine
which personal belongings stay with the body(wedding or religious symbols) and give
other personal items to family members
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