Before rigor mortis occurs, what is the nurse responsible for?

Correct Answer: B

Rationale: Before rigor mortis occurs, it is essential to place a pillow under the body's head and shoulders to maintain proper positioning. This helps prevent postmortem changes and ensures a more dignified appearance. Providing a complete bath and dressing change, removing clothing, or wrapping the body in a shroud are tasks typically done after rigor mortis sets in or later in the postmortem care process. Allowing the body to relax normally does not address the need for proper positioning before rigor mortis occurs.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: The correct position for administering a cleansing enema is the Sims left lateral position. This position is preferred as it helps to facilitate the procedure by allowing gravity to assist in the flow of the enema solution. The individual lies on their left side with the right knee flexed towards the chest, which helps to promote retention of the enema solution and its distribution throughout the colon.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: During a client's first hospitalization, it is essential to keep unnecessary furniture out of the way to prevent obstacles and ensure a safe environment. This action helps reduce the risk of accidents or falls, promoting the client's safety and well-being. Keeping the lights on at all times may not be necessary and can disrupt the client's rest. Keeping side rails up at all times can restrict the client's movement and independence unnecessarily. Keeping all equipment out of view may hinder the healthcare team's ability to monitor and access necessary tools for providing care.

Correct Answer: D

Rationale: When a nurse finds a client's pulse rate to be above normal, it is documented as tachycardia. Tachycardia specifically refers to an elevated heart rate, while tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is an irregular heartbeat. Therefore, the correct term to describe an above-normal pulse rate is tachycardia.

Correct Answer: A

Rationale: Back Care involves caring for the back through activities such as massage, exercises, proper posture, and ergonomic practices to maintain spinal health and prevent injuries. Massage helps relieve muscle tension, improve circulation, and promote relaxation, making it an effective method for back care.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.