The hospice nurse assesses a client newly admitted to hospice care.
Which is the nurse's priority assessment?
Assess the client's medical diagnosis.
Assess the client's financial situation.
Assess the client's spiritual needs.
Assess the client's support system.
The Correct Answer is A
Determining priority assessments in hospice care requires applying Maslow's hierarchy and the nursing process. Understanding the medical diagnosis is foundational for anticipating physical needs, managing symptoms, and ensuring safety, which precedes addressing psychosocial, spiritual, or financial concerns during the initial admission phase.
Choice A rationale
Identifying the medical diagnosis is essential for clinical decision making and symptom management. It allows the nurse to anticipate complications, understand prognosis, and provide appropriate pharmacological interventions to ensure comfort, which is the primary goal of hospice.
Choice B rationale
While financial stability affects long term care planning, it is not the immediate clinical priority upon admission. Basic physiological needs and medical stability must be addressed before the nurse evaluates the client's insurance coverage or socioeconomic status.
Choice C rationale
Spiritual assessment is a core component of holistic hospice care, yet it follows physical stabilization. The nurse must first ensure the client is not in acute physical distress before exploring religious beliefs or existential concerns.
Choice D rationale
Assessing the support system is vital for planning home care and caregiver respite. However, without understanding the medical condition first, the nurse cannot accurately determine the level of support or specific skills the family needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Analyzing arterial blood gas results requires understanding the relationship between hydrogen ion concentration, carbon dioxide levels, and bicarbonate. Knowledge of respiratory physiology is essential to determine if the primary imbalance stems from gas exchange failure or metabolic dysfunction in the body.
Choice A rationale
Metabolic acidosis is defined by a low pH and a low bicarbonate level below 22 mEq/L. In this case, the bicarbonate is 26 mEq/L, which is within the normal range of 22 to 28 mEq/L, ruling it out.
Choice B rationale
Respiratory alkalosis occurs when the pH is above 7.45 and the PaCO2 is below 35 mm Hg. This client has a low pH of 7.22 and a high PaCO2 of 68 mm Hg, which indicates an acidotic state.
Choice C rationale
Metabolic alkalosis is characterized by a high pH above 7.45 and an elevated bicarbonate level. This client presents with a low pH and a normal bicarbonate level, which does not fit the criteria for a metabolic alkalotic imbalance.
Choice D rationale
The pH of 7.22 is below 7.35, indicating acidosis. The PaCO2 of 68 mm Hg is above the normal 35 to 45 mm Hg range, confirming a respiratory cause. A respiratory rate of 7/min causes CO2 retention.
Correct Answer is ["10"]
Explanation
Step 1 is (1 unit ÷ 10 units) × 100 mL.
Step 2 is 0.1 × 100 mL.
Step 3 is 10 mL.
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