medium · NCLEX-RN basic-care
A 68-year-old client with end-stage renal disease has transitioned to comfort care in a hospice facility. The client is unresponsive, positioned in a semi-Fowler's position, and has loud, wet, gurgling respirations. The client's caregiver is highly distressed, crying, and asks the nurse, 'Please, can't you do something to stop that horrible choking sound?' Which action should the nurse take first?
- Explain to the caregiver that this is a normal part of dying and that no active clinical interventions are required.
- Turn the client to a lateral side-lying position and administer ordered sublingual atropine drops.
- Vigorously suction the client’s mouth, pharynx, and upper trachea to physically remove the secretions.
- Request an order to insert an oral pharyngeal airway to keep the tongue from obstructing the airway.
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