The nurse is providing end-of-life care and determines the patient is experiencing critical distress related to concerns about the afterlife. Which portion of the nursing process should the nurse use to guide the plan of care?

Planning.

Assessment.

Analysis.

Implementation.

Answer and Explanation

The Correct Answer is A

Choice A reason: Planning guides end-of-life care by developing interventions to alleviate anxiety about the future, identified during assessment. Anxiety activates the amygdala, increasing stress hormones. Planning may include spiritual support or counseling, addressing psychological needs to reduce distress, ensuring a tailored care plan promotes comfort and dignity at end-of-life.

Choice B reason: Assessment identifies anxiety but does not guide the care plan directly. It collects data (e.g., verbalized fears) about future concerns, while planning translates this into interventions, like spiritual care. Anxiety’s physiological effects (e.g., elevated cortisol) require targeted strategies, making planning the step to address these needs effectively.

Choice C reason: Analysis interprets data to diagnose anxiety, but the question states it’s already identified. Planning follows, creating interventions to reduce end-of-life distress, such as meditation or family involvement. Anxiety disrupts emotional regulation via the limbic system, requiring a structured plan to implement relief, making analysis secondary here.

Choice D reason: Implementation enacts the care plan, but anxiety about the future requires planning to design interventions first. Actions like providing spiritual resources follow action development to address psychological distress. Anxiety increases sympathetic activity, and planning ensures interventions target this, making implementation premature without a defined strategy.

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Correct Answer is C

Explanation

Choice A reason: Sending the UAP for N95 fitting is unnecessary, as meningococcal pneumonia requires droplet precautions, not airborne. Droplet transmission involves large particles, blocked by standard masks within 6 feet. N95 masks are for airborne diseases (e.g., tuberculosis), which involve smaller aerosols, making this action excessive and inefficient for safe care.

Choice B reason: Advising a standard mask for vital signs and N95 for personal care is incorrect, as meningococcal pneumonia requires only droplet precautions. Standard masks protect against droplet transmission during close contact. Requiring N95 overcomplicates care, as it’s designed for airborne pathogens, not relevant here, risking confusion and resource misuse.

Choice C reason: A standard face mask is sufficient for droplet precautions in meningococcal pneumonia, as it blocks large respiratory droplets containing Neisseria meningitidis during close contact. Droplet transmission does not require N95 masks, which are for airborne pathogens. This ensures safe, efficient care, protecting the UAP without unnecessary equipment, making it the correct action.

Choice D reason: Determining staff with fitted N95 masks is irrelevant, as meningococcal pneumonia requires droplet, not airborne, precautions. Standard masks suffice for droplet transmission, preventing bacterial spread via respiratory secretions. N95 masks are for smaller aerosols, not applicable here, making reassignment based on N95 fitting unnecessary and inefficient.

A. Apply a debriding agent. B. Remove every other suture. C. Apply steri-strips. D. Obtain a wound culture.

Correct Answer is D

Explanation

Choice A reason: Applying a debriding agent is premature without confirming infection, as thick tan exudate may indicate pus. A wound culture identifies pathogens first, guiding treatment. Debridement risks unnecessary tissue damage if not indicated, per wound management and infection control protocols in surgical care.

Choice B reason: Removing sutures is inappropriate, as secondary intention wounds typically lack sutures, healing via granulation. Thick exudate suggests infection, requiring a culture first. Suture removal is irrelevant and risks delaying diagnosis, per principles of wound healing and infection assessment in secondary intention wounds.

Choice C reason: Applying steri-strips is unsuitable for secondary intention wounds, which heal openly without closure. Thick tan exudate warrants a culture to rule out infection before interventions. Steri-strips do not address potential infection, delaying appropriate care, per wound management and surgical nursing standards.

Choice D reason: Obtaining a wound culture is the priority, as thick tan exudate may indicate infection in a secondary intention wound. Identifying pathogens guides antibiotic therapy, preventing sepsis or delayed healing. This aligns with evidence-based wound assessment, ensuring timely and targeted treatment, per infection control and surgical care protocols.

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The nurse is providing end-of-life care and determines the patient is experiencing critical distress related to concerns about the afterlife. Which portion of the nursing process should the nurse use to guide the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An unlicensed assistive personnel (UAP) is assigned to feed a client with meningococcal pneumonia for whom droplet precautions have been implemented. The UAP requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?

Correct Answer is C

Explanation

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Correct Answer is D

Explanation

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver is the primary caregiver. While planning care, which problem has the highest priority?

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. Which intervention is most important for the nurse to implement before leaving the client alone?

A client requests heat therapy for lower back pain. Which action should the nurse take?

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

The nurse is planning care for the elimination needs of a group of clients. The nurse determines a bedpan will be needed for which client?

A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?