hard · NCLEX-RN basic-care
An 85-year-old client with end-stage stomach cancer is in the final days of life in home hospice. The client has developed loud terminal secretions ('death rattle'). The caregiver is highly anxious and demands, 'Please start an IV line so we can hydrate her. Her mouth is dry and she is dehydrating.' Which actions are appropriate for the nurse to take? Select all that apply.
- Offer to moisten the client's lips and mucous membranes with water-soluble lubricant and oral swabs.
- Check the client's urinary output hourly to monitor renal perfusion.
- Explain that terminal secretions are saliva pooling due to relaxed throat muscles and are not associated with a choking sensation.
- Obtain an order to start normal saline at 100 mL/hr to relieve the caregiver's distress.
- Explain to the caregiver that starting intravenous fluids will increase the pooling of secretions in the lungs, worsening her breathing.
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