# Stage 5 — Take action. Place the five nursing actions in the safest sequence for the initial comfort-care cycle. Brief explanation to the family occurs during the bedside actions rather than waiting until the cycle ends.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372808&lang=en  
> language: en  
> subject: Personal Hygiene  
> category: BCC

## Question

Stage 5 — Take action. Place the five nursing actions in the safest sequence for the initial comfort-care cycle. Brief explanation to the family occurs during the bedside actions rather than waiting until the cycle ends.

Raise the head of the bed, use a supported side-lying position, provide gentle mouth care, and continue oxygen if it improves observed comfort.

Document the assessment, route-safety decision, interventions, response, notifications, and the family's questions, preferences, and understanding.

Confirm the documented goals and current orders, rapidly assess behavioral distress and reversible contributors, identify unsafe swallowing, and explain the immediate plan to the family.

Reassess respiratory effort, facial tension, restlessness, secretions, medication effects, and family understanding; contact the hospice prescriber if distress persists.

Administer the prescribed subcutaneous morphine for dyspnea or pain and the individualized secretion or agitation medication only when its target symptom is present.

## Explanation

Safest sequence
1) Confirm, assess, protect the route, and explain (choice 3). 2) Position, provide mouth care, and continue comfort-beneficial oxygen (choice 1). 3) Give prescribed medication matched to the observed target symptom (choice 5). 4) Reassess the client and family and escalate unresolved distress (choice 2). 5) Document the cycle (choice 4). Family communication begins during assessment and continues throughout; it is not delayed until the client appears calmer.

## In-depth explanation

Why the order matters
A rapid assessment identifies dyspnea, possible pain, agitation causes, and unsafe swallowing while confirming which interventions match the current plan. Low-burden bedside measures can begin immediately. Prescribed medications then target observed symptoms through a safe route.

Close the feedback loop
Reassessment is a separate clinical action: observe breathing effort, facial relaxation, restlessness, secretion burden, adverse effects, and the family's understanding. Persistent or worsening distress requires hospice specialist or prescriber input.

Communication is concurrent
Explain what is happening and invite family participation while care is delivered. The family's questions are not postponed for the sake of a rigid task list.

## Clinical scenario

Scenario (Stage 5 — Take action)
The client cannot safely swallow and needs an immediate, observable comfort-care cycle with the family present.

Clinical judgment target
Sequence assessment, low-burden care, targeted medication, reassessment, and documentation while communicating throughout.

## Key concepts

- **Comfort-care cycle** — Confirm goals and orders, assess, intervene through safe routes, reassess effect and harm, escalate unresolved distress, and document.
- **Target-symptom prescribing** — Match each as-needed medicine to a present symptom such as dyspnea, pain, anxiety, agitation, or distressing secretions rather than administering a routine bundle automatically.
- **Concurrent family communication** — Explain observed changes, actions, expected effects, and uncertainty while care occurs; validate concerns and check understanding throughout the encounter.

## Related questions

- [A hospice nurse is planning pain management for a client with metastatic cancer who can ta…](https://mymerci.kr/pages/nclex_q.php?qn_id=363998&lang=en)
- [A nurse is creating a pressure injury prevention plan for an immobile older adult admitted…](https://mymerci.kr/pages/nclex_q.php?qn_id=366392&lang=en)
- [A dying client's family asks to perform meaningful spiritual and cultural rituals at the b…](https://mymerci.kr/pages/nclex_q.php?qn_id=368302&lang=en)
- [A nurse cares for family members after a loved one is told that an illness is terminal. Wh…](https://mymerci.kr/pages/nclex_q.php?qn_id=368324&lang=en)
- [A 62-year-old client with chronic low-back pain has taken sustained-release morphine 30 mg…](https://mymerci.kr/pages/nclex_q.php?qn_id=369152&lang=en)
- [A community health nurse is leading an advance care planning education session at a senior…](https://mymerci.kr/pages/nclex_q.php?qn_id=372705&lang=en)
- [Stage 4 — Generate solutions. Select all nursing actions that belong in Mr. K's individual…](https://mymerci.kr/pages/nclex_q.php?qn_id=372807&lang=en)
- [Stage 6 — Evaluate outcomes. Review the day-shift trajectory and answer the three question…](https://mymerci.kr/pages/nclex_q.php?qn_id=372809&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=372808&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=372808&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=372808&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=372808&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=372808&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._