Question

A nurse is caring for a client who has terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

A. turn the client q2hrs
B. administer an antiemetic (prevents N/V) q6hrs
C. hold oral care
D. increase room temperature

Answer 1

The nurse should turn the client every 2 hours to help clear secretions and provide comfort. Providing consistent oral care is also essential. Antiemetics and changing the room temperature are not directly related to the client's respiratory symptoms.

Step-by-step explanation:

The nurse should turn the client every 2 hours (A) to promote lung expansion and help mobilize and clear secretions. This practice, known as repositioning, can alleviate shortness of breath and is part of standard palliative care protocols to improve comfort for a client with a terminal illness. Turning the client can also help prevent pressure ulcers and improve circulation. Providing oral care is also crucial to maintain oral hygiene and comfort, and to help manage secretions, not holding it (C).

Administering an antiemetic every 6 hours (B) may be irrelevant in this case unless nausea and vomiting are also present. Increasing the room temperature (D) will not specifically address the client's noisy respirations and may even cause discomfort if the temperature becomes too warm.

In summary, regular turning and oral care, along with other measures such as suctioning if needed, opioid administration for dyspnea, or anticholinergic drugs to dry up secretions, are appropriate interventions for a client experiencing shortness of breath and noisy respirations due to terminal illness.