Nur 340L-Final Exam Questions and Complete Solutions
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NUR 340
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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 solutio
signs that death has occured absence of heartbea
what does federal and state laws require that inst
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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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