medium · NCLEX-RN Basic Care and Comfort

An 85-year-old female client with end-stage renal failure is in the active phase of dying at home under hospice care. Her husband is weeping and highly distressed by her irregular breathing pattern, which alternates between rapid, deep breathing and long periods of apnea. He begs the nurse to call 911.

Which action should the nurse take?

  1. Contact the provider to request an emergency prescription for an intravenous respiratory stimulant, at this point in care.
  2. Instruct the husband to perform light chest compressions whenever she stops breathing for more than fifteen seconds.
  3. Explain that this irregular breathing pattern is normal at this stage, does not cause pain, and focus on holding her hand.
  4. Instruct the husband to apply a high-flow oxygen mask and begin rescue breathing immediately.

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